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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Moderate variability in the FHR is a reassuring sign of fetal well-being, indicating a responsive fetal autonomic nervous system to normal physiologic stimuli. It is considered a normal finding in active labor, suggesting that the fetus is well-oxygenated and able to cope with contractions.
Choice B rationale:
Prolonged decelerations are concerning patterns on the fetal heart rate (FHR) monitor, indicating potential fetal distress. Prolonged decelerations are defined as lasting more than 2 minutes but less than 10 minutes. These decelerations can be caused by umbilical cord compression, placental insufficiency, or maternal hypotension. Prompt intervention is required, making this choice the correct answer.
Choice C rationale:
Three uterine contractions within 10 minutes, also known as a contraction stress test (CST), is a normal finding. It assesses the fetal response to stress and is used to evaluate the placental function and fetal well-being.
Choice D rationale:
A baseline FHR of 115/min is within the normal range (110-160 beats per minute) for a term fetus. It indicates a stable fetal heart rate, and there is no immediate need for intervention.
Correct Answer is A
Explanation
Choice A rationale:
Glargine insulin is a long-acting insulin that provides a basal level of insulin over 24 hours. It is suitable for managing blood glucose levels in clients with diabetes mellitus who require a long-acting insulin to maintain glycemic control throughout the day.
Choice B rationale:
NPH insulin is an intermediate-acting insulin that lasts for about 12-16 hours. While it can be used for blood glucose management, it is not the best choice for a client needing long-acting insulin coverage throughout the day.
Choice C rationale:
Insulin aspart is a rapid-acting insulin used to control postprandial glucose levels. It acts quickly to lower blood sugar after meals and is not suitable for long-acting coverage.
Choice D rationale:
Regular insulin, also known as short-acting insulin, is used to control blood glucose levels during meals. It has a faster onset of action compared to long-acting insulins and is not appropriate for managing basal insulin needs over an entire day.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.