A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?
Pin-point pupils
Irritability
Pallor
Decreased blood pressure
The Correct Answer is B
A. Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light
B. Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C. Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.
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Related Questions
Correct Answer is C
Explanation
c. Diminished pulses on the affected extremity. This finding may indicate compromised circulation, which is
a serious complication that requires immediate intervention.
Option a. Ecchymosis on the inner left thigh may be a concerning finding, but it is not as urgent as diminished pulses. Ecchymosis may be a result of trauma during cast application, and may resolve on its own.
Option b. One fingerbreadth of space between the cast and the skin is a normal finding and indicates that the cast is not too tight.
Option d. Client report of muscle spasms of the left leg is a common complaint in clients with casts and may
be addressed with medication or other interventions, but it is not as urgent as diminished pulses. Therefore, the priority finding in this scenario is c. Diminished pulses on the affected extremity.
Correct Answer is C
Explanation
Albuterol is a bronchodilator medication that is commonly delivered through a metered-dose inhaler (MDI) to treat asthma and other respiratory conditions. Proper inhaler technique is crucial for the effective delivery of the medication to the lungs.
Option (a) is incorrect because the client should actually tilt their head back slightly and breathe out fully before inhaling the medication.
Option (b) is incorrect because the client should take a slow, deep breath while depressing the canister once.
Option (d) is incorrect because the client should hold their breath for 10 seconds after inhaling the medication to allow it to reach the lungs.
Therefore, the correct instruction for the nurse to include in the teaching is to instruct the client to close their mouth around the mouthpiece of the inhaler to ensure that the medication is delivered directly to the lungs.
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