A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Amnesia.

Tachycardia.

Altered level of consciousness.

Hypotension.

Answer and Explanation

The Correct Answer is C

Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.

Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.

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Correct Answer is C

Explanation

0745.. Regular insulin has an onset of action of 30 to 60 minutes, a peak effect of 2 to 4 hours, and a duration of action of 6 to 8 hours. Therefore, the patient should receive breakfast within 30 minutes of receiving the insulin injection to prevent hypoglycemia.

Choice A. 0720 is incorrect because it is too soon after the injection and the insulin may not have reached its onset of action yet.

Choice B. 0815 is incorrect because it is too late after the injection and the insulin may have reached its peak effect by then, increasing the risk of hypoglycemia.

Choice D. 0730. is incorrect because it is less than 30 minutes after the injection and the insulin may be approaching its peak effect.

A. Stuporous level of consciousness B. Seizure activity C. Pathological change on CT scan D. Bradycardia

Correct Answer is B

Explanation

When a client is experiencing alcohol withdrawal, seizures are a common finding. Benzodiazepines are the preferred medications for alcohol withdrawal, and they are used to prevent seizures and treat symptoms of anxiety, agitation, and autonomic hyperactivity. Stuporous level of consciousness (Choice A), pathological changes on a CT scan (Choice C), and bradycardia (Choice D) are unlikely findings in a client experiencing alcohol withdrawal. Stuporous level of consciousness is more indicative of acute brain dysfunction or coma. CT scan findings may indicate structural brain injury, such as a brain tumor or stroke. Bradycardia is not a common finding in alcohol withdrawal but may occur in severe cases. However, tachycardia is a more common finding.

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A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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