A nurse notes an increased heart rate in a patient with heart failure. Which compensatory mechanism is likely at play?

Increased secretion of natriuretic peptides

Activation of the sympathetic nervous system

Increased cardiac fibrosis

Inhibition of the renin-angiotensin-aldosterone system

Answer and Explanation

The Correct Answer is B

A. Natriuretic peptides promote vasodilation and diuresis but do not directly increase heart rate.
B. Activation of the sympathetic nervous system increases heart rate and contractility to maintain cardiac output in heart failure.
C. Cardiac fibrosis is a pathological change, not a compensatory mechanism causing increased heart rate.
D. The renin-angiotensin-aldosterone system is usually activated, not inhibited, in heart failure.

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Correct Answer is C

Explanation

A. Trendelenburg position (head lower than feet) can increase intracranial pressure and is contraindicated.
B. Continuous rotation may increase ICP due to frequent position changes and is generally avoided.
C. Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, helping reduce intracranial pressure while maintaining cerebral perfusion.
D. Keeping the head flat can impair venous drainage and increase ICP.

A. Arms flexed at the elbows, with the hands and wrists bent toward the chest B. Grimacing in pain when the neck is flexed, causing the legs to bend at the knee C. The nurse is unable to extend the leg when the hip is flexed without causing the patient to grimace in pain D. Arms extended, rigidly held straight out with palms of the hands turned away from the body

Correct Answer is A

Explanation

A. Decorticate posturing is characterized by arms flexed at the elbows with wrists and fingers bent inward toward the chest, indicating damage to the cerebral hemispheres or corticospinal tract.
B. Grimacing and leg movement with neck flexion describe a positive Brudzinski’s sign, related to meningeal irritation, not posturing.
C. Inability to extend the leg with hip flexion causing pain describes a positive Kernig’s sign, also related to meningeal irritation.
D. Arms extended and rigid with palms turned outward describe decerebrate posturing, indicating more severe brainstem injury.

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A nurse notes an increased heart rate in a patient with heart failure. Which compensatory mechanism is likely at play?

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Naxlex Comprehensive Predictor Exams

A nurse plans care for the patient with increased intracranial pressure with the knowledge that the best way to position the patient is to

Correct Answer is C

Explanation

An acute care nurse receives a shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

Correct Answer is A

Explanation

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