A nurse is caring for a patient in the intensive care unit who was admitted with severe head trauma and cerebral edema. The patient opens their eyes spontaneously, is oriented, and obeys commands.Which of the following findings indicate the patient is experiencing a decline in their condition?

Patient is confused

Patient mumbles inappropriate words

Eyes do not open to name

Answer and Explanation

The Correct Answer is A

Choice A rationale
A patient in the intensive care unit who was admitted with severe head trauma and cerebral edema, who opens their eyes spontaneously, is oriented, and obeys commands, would be experiencing a decline in their condition if they become confused. Confusion can be a sign of worsening brain function, indicating that the brain is not receiving enough oxygen or is being affected by a buildup of toxins. This could be due to increased intracranial pressure, decreased blood flow to the brain, or further injury to the brain tissue.
Choice B rationale

Mumbling inappropriate words can also be a sign of a decline in a patient’s condition. However, it is less specific than confusion. It could be due to a variety of factors, including medication side effects, sleep deprivation, or mental health issues.
Choice C rationale
If a patient’s eyes do not open to their name, it could indicate a significant decline in their condition. However, this is a more severe symptom than confusion and may not be the first sign of a decline.

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Correct Answer is C

Explanation

Choice A rationale
Nicardipine is a calcium channel blocker used to treat high blood pressure. While it can be used in the management of subarachnoid hemorrhage, it is not primarily used to decrease intracranial pressure.
Choice B rationale

Dopamine is a type of medication used to treat certain conditions such as low blood pressure, heart failure, and Parkinson’s disease. It is not typically used to decrease intracranial pressure in the context of a subarachnoid hemorrhage.
Choice C rationale
Mannitol is a type of medication that is used to decrease intracranial pressure. It works by drawing fluid out of the brain to help reduce swelling.
Choice D rationale
Phenytoin is a medication used to control seizures. While it can be used in the management of subarachnoid hemorrhage, it is not primarily used to decrease intracranial pressure. Migraine Explore

A. Pulmonary embolus B. Bacterial translocation C. Deep vein thrombosis D. Myocardial infarction

Correct Answer is B

Explanation

Choice A rationale
Pulmonary embolus is a serious condition that can occur due to prolonged immobility, but it is not directly related to the timing of enteral nutrition in a client with increased intracranial pressure.

Choice B rationale
Bacterial translocation refers to the migration of bacteria from the gut to other areas of the body. Early enteral nutrition (within 24 to 48 hours) in critically ill patients can help maintain the integrity of the gut mucosa and prevent bacterial translocation. Therefore, starting enteral nutrition within this timeframe can help prevent bacterial translocation.
Choice C rationale
Deep vein thrombosis, like pulmonary embolus, is a risk due to immobility but is not directly related to the timing of enteral nutrition.
Choice D rationale
Myocardial infarction is a cardiac event that could be related to overall cardiovascular health, stress, or specific injury to the cardiac muscle. It is not directly prevented by the initiation of enteral nutrition.

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A nurse is caring for a patient in the intensive care unit who was admitted with severe head trauma and cerebral edema. The patient opens their eyes spontaneously, is oriented, and obeys commands.Which of the following findings indicate the patient is experiencing a decline in their condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting a patient with a subarachnoid hemorrhage and expects to administer which of the following medications to decrease intracranial pressure (ICP)?

Correct Answer is C

Explanation

A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Correct Answer is B

Explanation

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