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: Changing the ostomy pouch daily is not typically necessary. Most pouches can be worn comfortably for several days before needing to be changed. Frequent changes are not only unnecessary but can also irritate the skin around the stoma.

Choice B reason: Emptying the ostomy pouch when it is 2/3 full is recommended to prevent leaks and overfilling, which can lead to discomfort and potential skin irritation. It is important to monitor the fullness of the pouch and empty it regularly to maintain hygiene and comfort.

Choice C reason: Trimming the opening of the ostomy seal to be 1/2 inch wider than the stoma is incorrect. The opening should be cut to match the size of the stoma to ensure a snug fit that prevents leakage and protects the skin around the stoma.

Choice D reason: Applying lotion to the peristomal skin when changing the ostomy pouch is not advised. Lotions or creams can interfere with the adhesive of the ostomy appliance and should be avoided. The peristomal skin should be clean and dry to ensure proper adhesion of the ostomy appliance.

A. "I take my other pills at least 30 minutes after my alendronate." B. "I take my alendronate on the same day every week with an 8-ounce glass of milk." C. "I sit up and read the morning paper after taking my alendronate." D. "I will need to have a bone density test occasionally while taking this medication."

Correct Answer is B

Explanation

Choice A reason: This statement does not indicate a need for further instruction. It is recommended to take other medications at least 30 minutes after alendronate to ensure proper absorption of the drug.

Choice B reason: This statement indicates a need for further instruction. Alendronate should be taken with plain water, not milk. The calcium in milk can interfere with the absorption of alendronate.

Choice C reason: This statement is correct and does not indicate a need for further instruction. Patients are advised to stay upright for at least 30 minutes after taking alendronate to prevent esophageal irritation or reflux.

Choice D reason: This statement is correct and does not indicate a need for further instruction. Periodic bone density tests are necessary to monitor the effectiveness of alendronate therapy in treating osteoporosis.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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