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
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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Correct Answer is C
Explanation
To prevent autonomic dysreflexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreflexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.
a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreflexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreflexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreflexia.
Correct Answer is B
Explanation
The nurse should identify that developing a respiratory infection can cause a myasthenic crisis in a client who has myasthenia gravis. A myasthenic crisis is a sudden worsening of myasthenia gravis symptoms, which can include difficulty breathing and swallowing. Respiratory infections can exacerbate these symptoms and trigger a myasthenic crisis.
Taking too much-prescribed medication, insufficient exercise, and insufficient sleep are not factors that can cause a myasthenic crisis. Taking too much-prescribed medication can cause side effects but would not directly cause a myasthenic crisis. Insufficient exercise and insufficient sleep can worsen overall health but would not directly cause a myasthenic crisis.
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