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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason

Increased erythrocyte sedimentation rate (ESR) is a marker of inflammation and is commonly elevated in conditions like rheumatoid arthritis. However, it is not a direct adverse effect of NSAID therapy. NSAIDs are more likely to cause gastrointestinal issues, such as bleeding, which would be detected by a fecal occult blood test.

Choice B Reason

Elevated creatinine clearance is not typically associated with NSAID use. In fact, NSAIDs can potentially reduce kidney function, leading to decreased creatinine clearance. Therefore, this option is incorrect.

Choice C Reason

Increased serum potassium levels can occur with NSAID use, especially in patients with compromised kidney function. However, this is less common compared to gastrointestinal bleeding, which is a more direct and frequent adverse effect of NSAID therapy.

Choice D Reason

Positive fecal occult blood test is the correct answer. NSAIDs can cause gastrointestinal bleeding, which can be detected through a fecal occult blood test. This is a well-documented adverse effect of NSAID therapy and is a significant concern for patients on long-term NSAID treatment.

A. Decreasing leg strength B. Decreasing voice volume C. Decreased deep tendon reflexes D. Decreased sensation in the arms

Correct Answer is B

Explanation

Choice A Reason:

Decreasing leg strength is a common symptom of Guillain-Barré syndrome (GBS) and indicates the progression of muscle weakness. While it is concerning and should be monitored, it is not as immediately critical as respiratory complications.

Choice B Reason:

Decreasing voice volume can indicate involvement of the cranial nerves and potential respiratory muscle weakness, which can lead to respiratory failure. This is an urgent finding that requires immediate attention to prevent respiratory complications.

Choice C Reason:

Decreased deep tendon reflexes are a hallmark of GBS and are expected in the progression of the disease. While they should be documented and monitored, they do not require immediate reporting unless accompanied by other critical symptoms.

Choice D Reason:

Decreased sensation in the arms is another common symptom of GBS due to peripheral nerve involvement. It should be monitored, but it is not as urgent as signs of respiratory compromise.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing laboratory reports for a client who is taking NSAIDs for rheumatoid arthritis. Which of the following results should the nurse recognize as a possible adverse effect of NSAID therapy?

Correct Answer is D

Explanation

A nurse is assessing a client who has Guillain-Barré syndrome. Which of the following findings should the nurse report to the provider immediately?

Correct Answer is B

Explanation

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