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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Hypertension with bradycardia is characteristic of autonomic dysreflexia due to the exaggerated sympathetic response causing increased blood pressure while the body compensates with bradycardia.
B. Hypotension with tachycardia is not indicative of autonomic dysreflexia; instead, it suggests different underlying issues.
C. While hypertension can occur in autonomic dysreflexia, it is typically accompanied by bradycardia, not tachycardia.
D. Hypotension with bradycardia does not correlate with autonomic dysreflexia and suggests other health complications.

A. Edema of the ear canal. B. Purulent drainage from the ear canal. C. Burning in the ear canal. D. Pain when moving the auricle. E. External ear tender to touch.

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

Explanation

A. Edema of the ear canal is a common symptom of external otitis, indicating inflammation and infection in the area.
B. Purulent drainage from the ear canal often signifies bacterial infection and is a key symptom to monitor.
C. Burning in the ear canal can occur due to inflammation and is a common complaint in external otitis.
D. Pain when moving the auricle is a classic symptom of external otitis, indicating irritation or inflammation of the external ear.
E. Tenderness of the external ear is a common finding in external otitis and should be monitored as it indicates inflammation and potential infection.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with autonomic dysreflexia. The nurse correlates which clinical manifestations to autonomic dysreflexia in a client with a spinal cord injury?

Correct Answer is A

Explanation

A nurse is caring for a client that has been diagnosed with external otitis. Which of the following clinical symptoms should the nurse be monitoring?

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

Explanation

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