A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Tachypnea

Hypotension

Decreased level of consciousness

Bilateral weakness of extremities

Answer and Explanation

The Correct Answer is C

Choice A: Tachypnea Tachypnea, or rapid breathing, is not typically a direct sign of increased ICP. While it can be associated with various medical conditions, it is not specifically indicative of increased ICP. However, it’s important to note that breathing patterns can change with advanced ICP changes, but these are usually characterized by irregularities rather than just increased rate. Increased intracranial pressure (ICP) is a critical condition that can occur after a traumatic brain injury (TBI). It results from the brain tissue’s response to injury, leading to swelling or bleeding within the skull. The skull is a rigid structure, so any increase in content, such as blood or edema, can lead to an increase in pressure.

Choice B: Hypotension Hypotension, or low blood pressure, is generally not associated with increased ICP. In fact, one of the signs of increased ICP is Cushing’s triad, which includes hypertension (high blood pressure), bradycardia (slow heart rate), and irregular respirations. Therefore, hypotension would not be a typical manifestation of increased ICP.

Choice C: Decreased level of consciousness A decreased level of consciousness is a hallmark sign of increased ICP. As pressure within the skull increases, it can lead to compression of the brain tissue and disruption of cerebral blood flow. This can manifest as changes in alertness, drowsiness, confusion, and in severe cases, loss of consciousness1. when monitoring a client who has sustained a TBI, the nurse should be vigilant for signs of increased ICP, with a decreased level of consciousness being a primary indicator. Other signs may include headache, nausea, vomiting, and changes in pupil size or reactivity. It is crucial to identify and treat increased ICP promptly to prevent further brain injury and potential long-term consequences.

Choice D: Bilateral weakness of extremities While bilateral weakness can be a sign of neurological damage, it is not specific to increased ICP. Increased ICP is more likely to cause global effects on consciousness and brain function rather than isolated weakness in limbs unless there is focal brain injury causing raised ICP.

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Correct Answer is C

Explanation

Choice A reason: Nausea and faintness Nausea and faintness can be symptoms of hypovolemic shock. Hypovolemic shock occurs when the body loses a significant amount of blood or fluids, leading to a decrease in blood pressure and inadequate oxygen supply to the organs. This can cause various symptoms, including nausea and faintness, as the body struggles to maintain normal function.

Choice B reason: Neurologic deficits and apprehension Neurologic deficits and apprehension can also be symptoms of hypovolemic shock. Neurologic deficits refer to abnormal neurologic function of a body area due to injury of the brain, spinal cord, muscles, or nerves. Apprehension, or anxiety, can occur as the body responds to the stress of significant blood or fluid loss.

Choice C reason: Hypertension and tachypnea Hypertension, or high blood pressure, is not typically a symptom of hypovolemic shock. In fact, hypovolemic shock is usually characterized by hypotension, or low blood pressure, due to the loss of blood or fluids. Tachypnea, or rapid breathing, can be a symptom of hypovolemic shock, but it would not typically be accompanied by hypertension in this context.

Choice D reason: Diaphoresis and oliguria Diaphoresis (excessive sweating) and oliguria (reduced urine production) can be symptoms of hypovolemic shock. Diaphoresis can occur as the body attempts to cool itself in response to the stress of significant blood or fluid loss. Oliguria can occur as the kidneys receive less blood flow due to the decrease in blood volume, leading to decreased urine production.

A. Hyperglycemia B. Disequilibrium syndrome C. Peritonitis D. Hyperphosphatemia E. The client experiences pain upon palpation of the epigastric region.

Correct Answer is A

Explanation

Choice A: Hyperglycemia The reason hyperglycemia is a risk when the prescribed dwell time is not maintained is due to the glucose present in the dialysate. The dialysate used in PD often contains glucose, which acts as an osmotic agent to facilitate fluid removal from the blood. If the dwell time is too short, there may not be enough time for the glucose to be absorbed, leading to higher levels of glucose in the blood. Conversely, if the dwell time is too long, excessive glucose absorption can occur, also leading to hyperglycemia. For patients with diabetes mellitus, maintaining the prescribed dwell time is essential to manage their blood glucose levels effectively. The normal range for fasting blood glucose is typically between 70 to 99 mg/dL, and for diabetes patients, maintaining blood glucose levels as close to the normal range as possible is crucial to prevent complications.

Choice B: Disequilibrium Syndrome Disequilibrium syndrome is characterized by neurological symptoms resulting from rapid changes in the composition of extracellular fluids during dialysis. This condition is more commonly associated with hemodialysis due to the rapid shifts that can occur with this modality. In PD, the risk of disequilibrium syndrome is significantly lower because the exchange of solutes and fluids is more gradual. Therefore, while important to consider, it is not the primary complication associated with the maintenance of dwell time in PD.

Choice C: Peritonitis Peritonitis, an infection of the peritoneal cavity, is a serious complication of PD but is not directly related to the duration of dwell time. It is typically caused by contamination during the exchange process or catheter-related infections. While proper technique and hygiene are critical in preventing peritonitis, the dwell time itself does not influence the risk of developing this infection.

Choice D: Hyperphosphatemia Hyperphosphatemia refers to elevated levels of phosphate in the blood and is a concern in patients with renal failure due to the kidneys’ inability to excrete phosphate effectively. The dwell time in PD may affect the removal of phosphate to some extent; however, it is not the primary concern related to the maintenance of dwell time. Phosphate binders and dietary restrictions are commonly used to manage phosphate levels in PD patients.

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A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

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