A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)
Infection
Vomiting
Widening pulse pressure
Equal and reactive pupils
Intracranial pressure reading of 10 mm Hg
Correct Answer : A,B,C
Choice A Reason:
Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.
Choice B Reason:
Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.
Choice C Reason:
Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.
Choice D Reason:
Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.
Choice E Reason:
An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Taking aspirin is generally not recommended for pain management in polycystic kidney disease (PKD) patients. Aspirin can cause gastrointestinal bleeding and may affect kidney function, which is already compromised in PKD patients. Instead, acetaminophen is often recommended for pain relief.
Choice B Reason:
Reducing dietary fiber intake is not typically advised for PKD patients. In fact, a balanced diet with adequate fiber is important for overall health and can help manage symptoms such as constipation, which can be a concern for PKD patients.
Choice C Reason:
Applying dry heat to the abdomen can help alleviate pain associated with PKD. Heat therapy can relax muscles and reduce discomfort caused by the enlarged kidneys and cysts. This non-pharmacological approach is safe and can be effective in managing pain.
Choice D Reason:
Checking weight once per week is not sufficient for PKD patients. Regular monitoring of weight is important to detect fluid retention and other complications. It is generally recommended to check weight more frequently, such as daily, to promptly identify any significant changes.
Correct Answer is A
Explanation
Choice A Reason:
Expressive aphasia, also known as Broca’s aphasia, is a common symptom of a left-hemisphere stroke. This condition affects the person’s ability to produce speech, although their comprehension may remain intact. The left hemisphere of the brain is typically responsible for language and speech functions, so damage to this area often results in expressive aphasia.
Choice B Reason:
Poor impulse control is more commonly associated with right-hemisphere strokes. The right hemisphere is involved in controlling behavior and emotions, so damage to this area can lead to impulsivity and poor judgment.
Choice C Reason:
Left hemiparesis, or weakness on the left side of the body, is typically a result of a right-hemisphere stroke. Strokes affect the opposite side of the body from the hemisphere where the stroke occurred. Therefore, a left-hemisphere stroke would more likely cause right-sided weakness or paralysis.
Choice D Reason:
Disorientation to place can occur with strokes affecting either hemisphere, but it is not a specific hallmark of left-hemisphere strokes. Cognitive impairments such as disorientation are more generalized and can result from various types of brain injuries.
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