A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

Tachycardia.

Hypotension.

Narrowed pulse pressure.

Increasingly severe headache.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Increasingly severe headache.

Choice A rationale:

Tachycardia is not typically associated with increased intracranial pressure (ICP). In fact, bradycardia (a slower heart rate) is more commonly seen as part of Cushing’s triad, which indicates increased ICP.

Choice B rationale:

Hypotension is not a common sign of increased ICP. Instead, hypertension (high blood pressure) is often observed as the body attempts to maintain cerebral perfusion pressure.

Choice C rationale:

Narrowed pulse pressure is not a typical indicator of increased ICP. Widened pulse pressure (the difference between systolic and diastolic blood pressure) is more commonly associated with increased ICP.

Choice D rationale:

Increasingly severe headache is a classic symptom of increased ICP. As pressure within the skull rises, it can cause significant pain and discomfort, making this a key indicator to monitor in patients with traumatic brain injury.

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Correct Answer is A

Explanation

Explanation: Sweet potato is a food that is high in potassium, which is an electrolyte that regulates fluid balance, nerve impulses, and muscle contractions in the body. A medium- sized sweet potato contains about 541 mg of potassium, which is more than 10% of the recommended daily intake for adults. Baked chicken breast, wheat bread, and canned green beans are foods that are low or moderate in potassium, containing less than 300 mg per serving.

A. Administering potassium via IV bolus. B. Leaving a nasogastric tube clamped after administering oral medication. C. Placing a yellow bracelet on a client who is at risk for falls. D. Documenting communication with a provider in the progress notes of the client's medical record.

Correct Answer is A

Explanation

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A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago. Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

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A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?