A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?

Papilledema

Restlessness

Projectile vomiting

Decorticate posturing

Answer and Explanation

The Correct Answer is B

Choice A reason: Papilledema, which is the swelling of the optic disc due to increased ICP, is not typically an early sign. It is usually a later manifestation because it takes time for the pressure to build up and affect the optic nerve.

Choice B reason: Restlessness can be an early sign of increased ICP. As ICP begins to rise, it can cause subtle changes in a person's level of consciousness, leading to agitation or restlessness. This is often one of the first signs that healthcare providers notice when monitoring for changes in neurological status.

Choice C reason: Projectile vomiting may occur with increased ICP, but it is not usually an early sign. It tends to occur after other symptoms such as headache and altered consciousness and is more indicative of significant pressure increases that affect the brainstem.

Choice D reason: Decorticate posturing is a severe sign of brain injury associated with increased ICP but is not an early sign. It indicates significant damage to the brain and is a late and ominous sign in the progression of increased ICP.

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Correct Answer is B

Explanation

Choice A reason: Thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland. While there are risks associated with any surgery, thyroidectomy is not typically associated with fat embolism syndrome (FES). FES is more commonly linked to orthopedic procedures and trauma, particularly those involving long bones.

Choice B reason: Internal fixation of a fractured hip is a procedure that carries a risk for developing FES. FES is a serious and potentially life-threatening condition that occurs when fat globules enter the bloodstream and lodge within the blood vessels of the lungs or other organs. Hip fractures, especially those involving the long bones, can result in the release of fat globules into the bloodstream during the surgical repair process. Early surgical fixation is thought to reduce the risk of FES.

Choice C reason: Repair of a torn rotator cuff involves the shoulder joint and, while it is a significant surgical procedure, it is not typically associated with a high risk of FES. The rotator cuff is composed of muscles and tendons, and its repair does not usually involve manipulation of the long bones where fat embolism is more likely to occur.

Choice D reason: Tympanoplasty is a surgical procedure to repair a hole in the eardrum. It is an otologic procedure that does not involve the long bones or orthopedic manipulation. Therefore, it is not associated with a risk of developing FES.

A. Hypotension B. Increased temperature C. Lethargy D. Decreased heart rate

Correct Answer is B

Explanation

Choice A reason: Hypotension, or low blood pressure, is not typically associated with thyroid storm. Thyroid storm is a life-threatening condition that often presents with hypertensive crisis due to the excessive amount of thyroid hormones accelerating the body's metabolism.

Choice B reason: Increased temperature is a hallmark sign of thyroid storm. Patients experiencing a thyroid storm can have a high fever, with temperatures ranging from 104°F to 106°F. This is due to the hypermetabolic state induced by excessive thyroid hormones, which increases the body's heat production.

Choice C reason: Lethargy is not a common symptom of thyroid storm. Instead, patients may experience agitation, irritability, and anxiety due to the overstimulation of the nervous system by excessive thyroid hormones. Lethargy might be observed in hypothyroidism, which is the opposite condition.

Choice D reason: A decreased heart rate is not characteristic of thyroid storm. On the contrary, tachycardia, or a rapid heart rate, is a common symptom. The heart rate can exceed 140 beats per minute as the body's demand for oxygen increases due to the hypermetabolic state.

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A nurse is caring for a client who is experiencing an increase in intracranial pressure (ICP). The nurse should expect which of the following as an early manifestation of increased ICP?

Nursing Test Bank

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