A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Nuchal rigidity

Batle's sign

Polyuria

Lethargy

Answer and Explanation

The Correct Answer is D

The nurse should monitor the client for lethargy as a manifestation of increased intracranial pressure. Increased intracranial pressure (ICP) is a rise in pressure around the brain that can occur due to various reasons such as brain injury, bleeding into the brain, swelling in the brain, or an increase in cerebrospinal ﬂuid. Lethargy (feeling less alert than usual) is a common symptom of increased ICP.

a. Nuchal rigidity is not a common symptom of increased ICP.
b. Batle's sign is not a common symptom of increased ICP.
c. Polyuria is not a common symptom of increased ICP.

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Free Nursing Study Resources

Correct Answer is A,B,C,D

Explanation

The order of the steps for the four-point alternate gait with crutches is as follows: move the right crutch about 10 to 15 cm (4 to 6 in), move the left foot forward, move the left crutch forward, and move the right foot forward. This gait patern provides maximum stability and support for the client by keeping three points of contact on the ground at all times.

A. Apply a compression bandage to the client's ankle. B. Apply heat to the client's ankle. C. Encourage range of motion of the client's foot. D. Elevate the client's foot. E. Check the client's toes for color, temperature, and sensation.

Correct Answer is ["A","D","E"]

Explanation

These are the correct interventions that the nurse should take. Applying a compression bandage to the client's ankle can help reduce swelling and provide support to the injured area. Elevating the client's foot can also help reduce swelling by promoting venous return. Checking the client's toes for color, temperature, and sensation is important to assess for any potential nerve or vascular damage.

Applying heat to the client's ankle is not recommended as it can increase swelling and inﬂammation. Encouraging range of motion of the client's foot is also not recommended as it can cause further injury to the aﬀected area.

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A nurse is assisting with caring for a client who has a new concussion following a motor-vehicle crash. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A,B,C,D

Explanation

A nurse in an urgent care centre is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. Which of the following interventions should the nurse take? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

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