A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Myocardial infarction

Bacterial translocation

Pulmonary embolus

Deep vein thrombosis

Answer and Explanation

The Correct Answer is B

A. Myocardial infarction: Enteral nutrition initiation within 24 to 48 hours is not directly associated with preventing myocardial infarction. While proper nutrition is important for overall cardiovascular health, the timing of enteral nutrition initiation primarily focuses on preventing complications related to increased intracranial pressure (ICP).

B. Bacterial translocation: Initiating enteral nutrition within 24 to 48 hours in clients with increased intracranial pressure helps prevent complications such as bacterial translocation. Bacterial translocation refers to the passage of bacteria from the gastrointestinal tract into the bloodstream and systemic circulation. Delayed initiation of enteral nutrition can lead to intestinal mucosal breakdown and increased intestinal permeability, facilitating bacterial translocation. Early enteral nutrition helps maintain intestinal mucosal integrity, reduces gut bacterial overgrowth, and decreases the risk of bacterial translocation, thereby lowering the risk of infectious complications.

C. Pulmonary embolus: Initiating enteral nutrition within 24 to 48 hours is not directly associated with preventing pulmonary embolus. Pulmonary embolism is a complication characterized by the obstruction of pulmonary arteries by blood clots, typically originating from deep vein thrombosis. Prevention of pulmonary embolus involves measures such as early mobilization, pharmacological prophylaxis, and mechanical compression devices to prevent venous stasis and thrombus formation.

D. Deep vein thrombosis: Initiating enteral nutrition within 24 to 48 hours is not directly associated with preventing deep vein thrombosis. Deep vein thrombosis is a complication characterized by the formation of blood clots within deep veins, commonly in the lower extremities. Prevention of deep vein thrombosis involves measures such as early mobilization, pharmacological prophylaxis, and mechanical compression devices to prevent venous stasis and thrombus formation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Septal myectomy: Septal myectomy is a surgical procedure primarily used to treat hypertrophic cardiomyopathy (HCM), not atrial fibrillation. It involves removing a portion of the thickened septal wall in the heart to improve blood flow.

B. Synchronized electrical cardioversion: Synchronized electrical cardioversion is a procedure used to convert abnormal heart rhythms, such as atrial fibrillation, back to normal sinus rhythm. It involves delivering a synchronized electrical shock to the heart at a specific point in the cardiac cycle to restore normal rhythm.

C. Pericardiocentesis: Pericardiocentesis is a procedure used to remove fluid from the pericardial sac surrounding the heart. It is typically performed to relieve cardiac tamponade or to investigate the cause of pericardial effusion.

D. Pericardial window: A pericardial window is a surgical procedure performed to create a permanent opening in the pericardium, the sac surrounding the heart. It is usually done to drain fluid or air from the pericardial space, often in cases of recurrent pericardial effusion or cardiac tamponade.

A. Respiratory rate of 12/min B. Blood pressure of 108/74 mm Hg C. Changes to pupil size and shape D. Swelling of the optic nerve E. Decreasing Glasgow Coma scores

Correct Answer is ["C","D","E"]

Explanation

A. Respiratory rate of 12/min: A respiratory rate of 12/min is within the normal adult range (12-20 breaths per minute). In the context of increased intracranial pressure (ICP), respiratory rate changes might be noted as part of the Cushing's reflex (which is characterized by bradycardia, hypertension, and abnormal respiratory patterns like Cheyne-Stokes or ataxic breathing), but a rate of 12/min on its own is not indicative of a worsening condition. However, if the patient begins to show signs of irregular or abnormal breathing patterns, this would raise concern.

B. Blood pressure of 108/74 mm Hg: This blood pressure is also within the normal range and does not suggest a worsening of intracranial pressure. In fact, ICP can lead to a rise in blood pressure (due to the body's compensatory mechanisms, known as Cushing's triad), along with bradycardia and abnormal respirations. Thus, a stable blood pressure like 108/74 mm Hg is not concerning in this context.

C. Changes to pupil size and shape: Changes in pupil size, shape, or reactivity are significant indicators of worsening intracranial pressure. Unequal pupils (anisocoria), sluggish or absent response to light, and fixed dilated pupils are signs of brainstem compression or damage, which often occur as ICP increases. This could indicate herniation or severe brain injury, which are worsening conditions.

D. Swelling of the optic nerve: Swelling of the optic nerve, or papilledema, is another important sign of increased intracranial pressure. It occurs due to increased pressure within the skull, which causes congestion and swelling of the optic disc. This finding can be seen on fundoscopy and indicates a worsening condition, as it suggests elevated pressure affecting the brain.

E. Decreasing Glasgow Coma scores: A decreasing Glasgow Coma Scale (GCS) score is a critical indicator of worsening neurologic function in a patient with increased ICP. The GCS is used to assess a patient's level of consciousness, and a decreasing score suggests that the brain's function is deteriorating. This can be caused by worsening edema, brain herniation, or other severe neurological impairments associated with elevated ICP.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is planning care for a client who has increased intracranial pressure. The nurse should understand that enteral nutrition should begin within 24 to 48 hr to help prevent which of the following complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has atrial fibrillation and reports heart palpitations, lightheadedness, and shortness of breath. Which of the following procedures should the nurse anticipate for this client?

Correct Answer is B

Explanation

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

Correct Answer is ["C","D","E"]

Explanation

A nurse is teaching a client who has symptomatic atrial fibrillation about manifestations to expect. Which of the following should the nurse include in the teaching? (Select All that Apply.)

A nurse is teaching a group of clients about risk factors for developing atrial flutter. Which of the following clients should the nurse understand is at highest risk for developing atrial flutter?

A nurse is planning care for a client who has hypertrophic cardiomyopathy that has not improved after pharmacologic treatment. Which of the following procedures should the nurse anticipate the health care provider ordering?

A nurse is planning care for a client who has peripheral venous disease. Which of the following interventions should the nurse include in the plan of care? (Select All that Apply.)

A nurse is teaching a client who has restrictive cardiomyopathy (RCM). Which of the following statements should the nurse include in the client teaching to explain the cause of RCM?

A nurse is obtaining a preoperative medical and surgical history from a client scheduled for a cataract extraction procedure. Which of the following client statements require further investigation by the nurse?

A nurse is providing care for a client who has delirium in the intensive care unit. Which of the following interventions should the nurse implement first to prevent client injury?

A nurse is teaching a client who has macular degeneration about how to use an Amsler grid. Which of the following statements should the nurse include in the teaching?