A nurse is caring for a client in an induced coma for increased intracranial pressure (ICP). What should the nurse assess next to determine this client's cerebral function?
Glasgow Coma Scale
Pupillary size and reaction
Blood pressure and heart rate
Gag Reflex
The Correct Answer is B
B. Assessing pupillary size and reaction provides critical information on brainstem function and can indicate changes in ICP. Changes in pupil size and reaction can signify worsening cerebral function or brain herniation.
A. The Glasgow Coma Scale is useful for assessing consciousness levels but may not be as sensitive for changes in brainstem function in a patient already in an induced coma.
C. Blood pressure and heart rate are vital signs that can suggest increased ICP, but they are not as direct an indicator of cerebral function as pupil assessment.
D. The gag reflex is important but does not provide as direct information about cerebral function related to ICP as pupillary assessment does.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Turning the client onto their operative side could increase pressure on the eye and is not an appropriate first action.
B. Administering prescribed pain medication and antiemetic is essential to address the client's severe pain and nausea, which are priority concerns in the postoperative period.
C. While it may be necessary to notify the surgeon if symptoms persist, the immediate priority is to alleviate the client's discomfort.
D. Reassuring the client that these symptoms are normal is misleading; severe pain and nausea postoperatively should be addressed promptly.
Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"A","dropdown-group-3":"E"}
Explanation
The nurse is assessing the client post-op and notes the client is complaining of tingling of the fingertips and assesses for Target 1: Chvostek sign; the nurse is aware if positive, the client likely has Target 2: hypocalcemia related to Target 3: disruption or removal of the parathyroid during surgery.
Rationale:
- Target 1: Chvostek sign - This is a clinical sign used to assess for neuromuscular excitability due to hypocalcemia. A positive Chvostek sign, which involves twitching of the facial muscles when tapping the facial nerve, indicates low calcium levels.
- Target 2: Hypocalcemia - The tingling sensation in the fingertips can be a symptom of hypocalcemia, which is a common complication following thyroidectomy due to potential damage or removal of the parathyroid glands.
- Target 3: Disruption or removal of the parathyroid during surgery - Parathyroid glands regulate calcium levels in the body. If these glands are disrupted or removed during thyroid surgery, it can lead to hypocalcemia.
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