A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
Hypertension
Tinnitus
Hypotension
Tachycardia
The Correct Answer is A
Choice A reason: Hypertension is a manifestation of increased intracranial pressure, as it reflects the body's attempt to maintain adequate cerebral perfusion pressure (CPP) and blood flow to the brain. CPP is the difference between the mean arterial pressure (MAP) and the intracranial pressure (ICP). When ICP rises, MAP must also rise to keep CPP constant and prevent cerebral ischemia. Hypertension is part of the Cushing's triad, which is a classic sign of increased ICP that also includes bradycardia and irregular respirations.
Choice B reason: Tinnitus is not a manifestation of increased intracranial pressure, as it does not affect the auditory system. Tinnitus is a ringing, buzzing, or hissing sound in the ears that can be caused by various factors, such as ear infections, noise exposure, medications, or aging. Tinnitus may be associated with other neurological conditions, such as Meniere's disease, acoustic neuroma, or multiple sclerosis, but not with increased ICP.
Choice C reason: Hypotension is not a manifestation of increased intracranial pressure, as it indicates a decrease in MAP and CPP, which can lead to cerebral ischemia and infarction. Hypotension can be caused by various factors, such as blood loss, dehydration, shock, or medications. Hypotension may worsen the outcome of increased ICP by reducing the oxygen and nutrient delivery to the brain.
Choice D reason: Tachycardia is not a manifestation of increased intracranial pressure, as it contradicts Cushing's triad. Tachycardia is an increase in heart rate that can be caused by various factors, such as anxiety, pain, fever, dehydration, or medications. Tachycardia may increase the oxygen demand and metabolic rate of the brain, which can exacerbate the effects of increased ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Asking how they are managing at home is an appropriate action by the nurse. It shows respect and interest in the client's situation and helps to assess their needs, challenges, and goals.
Choice B reason: Going automatically into the client's bedroom is not an appropriate action by the nurse. It violates the client's privacy and autonomy and may make them feel uncomfortable or threatened. The nurse should ask for permission before entering any room in the client's home.
Choice C reason: Arranging mutual future visits is an appropriate action by the nurse. It demonstrates collaboration and commitment and helps to establish a trusting relationship with the client. It also allows the nurse to plan and coordinate the care and follow-up.
Choice D reason: Thanking the client for arranging a home visit is not an appropriate action by the nurse. It implies that the home visit is a favor or a burden, rather than a professional service that the client is entitled to. It may also undermine the nurse's authority and credibility.
Choice E reason: Sitting down and discussing with the client and family members is an appropriate action by the nurse. It indicates that the nurse values the client's perspective and input, and recognizes the family as an important source of support and information. It also facilitates communication and education and promotes shared decision-making.
Correct Answer is D
Explanation
Choice A reason: A public health nurse is a nurse who works to improve the health and well-being of populations and communities, not specific workplaces. A public health nurse may focus on disease prevention, health promotion, environmental health, or emergency preparedness.
Choice B reason: A community nurse specialist is a nurse who has advanced education and training in a specific area of nursing practice, such as gerontology, oncology, or mental health. A community nurse specialist may work in various settings, such as hospitals, clinics, or schools, to provide specialized care and education to clients and families.
Choice C reason: A nurse clinician is a nurse who has expertise in clinical practice, research, and education. A nurse clinician may work in academic or clinical settings, such as universities, hospitals, or research centers, to develop and implement evidence-based practices and policies.
Choice D reason: An occupational health nurse is a nurse who works to protect and promote the health and safety of workers in various industries, such as manufacturing, mining, or construction. An occupational health nurse may provide services such as health assessment, injury prevention, emergency response, or wellness programs.
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