A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse that the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.)
Pupillary changes
Disorientation
Headache
Slurred speech
Neck pain and stiffness
Correct Answer : A,B,C,D
Choice A reason : Pupillary changes, such as unequal pupil sizes or a sluggish reaction to light, can be a sign of increased ICP. The cranial nerves that control the pupils may be compressed due to the swelling of the brain, leading to these changes¹.
Choice B reason : Disorientation, including confusion and changes in alertness, can occur with increased ICP as the pressure affects the brain's ability to process information and maintain consciousness².
Choice C reason : Headache is a common symptom of increased ICP. It can be severe and persistent due to the pressure exerted on the meninges and blood vessels within the brain³.
Choice D reason : Slurred speech may result from increased ICP if the areas of the brain responsible for speech and muscle control are affected by the pressure².
Choice E reason : Neck pain and stiffness, particularly when trying to flex the neck forward, can be indicative of meningeal irritation, which can be associated with increased ICP⁴.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Encouraging interaction with others by having the client share a room might be overwhelming for a client experiencing hypomanic episodes. Hypomania can involve irritability and impulsivity, making shared spaces potentially stressful. It's important to balance social interaction with the need for a controlled environment¹.
Choice B reason: Providing a calm atmosphere by placing the client in a private room can be beneficial for someone experiencing hypomanic episodes. A private room can reduce overstimulation and help manage symptoms like restlessness, agitation, and sleep disturbances. It allows the client to have a quiet space to retreat to, which can be crucial in managing mood swings¹².
Choice C reason: While a cheerful environment may seem beneficial, having bright drapes in the client's room could potentially contribute to overstimulation. Clients with hypomania are often sensitive to environmental stimuli, so it's important to keep the setting subdued to avoid exacerbating symptoms¹.
Choice D reason: Promoting access to activities by assigning the client to a room near the dayroom can be a double-edged sword. While it facilitates engagement in structured activities, which can be therapeutic, it also increases the risk of overstimulation due to the proximity to a potentially busy and noisy area. Careful consideration of the client's current state is necessary when making this decision¹.
Correct Answer is B
Explanation
Choice A reason : Avoiding exercise during flare-ups of fibromyalgia may seem intuitive to prevent exacerbating pain and fatigue. However, maintaining a gentle exercise routine, even during flare-ups, can help manage symptoms and prevent deconditioning¹.
Choice B reason : Establishing a regular sleep pattern is crucial for managing fibromyalgia. Poor sleep can exacerbate pain, fatigue, and cognitive difficulties commonly experienced with this condition. Good sleep hygiene practices can improve sleep quality and overall symptom management¹.
Choice C reason : While adequate calcium intake is essential for general health, there is no specific indication that increasing calcium intake alone would manage fibromyalgia symptoms. Nutritional needs should be addressed as part of a comprehensive approach to self-care¹.
Choice D reason : Yoga or running between flare-ups can be beneficial for clients with fibromyalgia. Regular exercise, including yoga, can improve pain, function, and quality of life. Running or other aerobic exercises can also be helpful if tolerated and done in moderation¹.
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