A patient is intubated and placed on a mechanical ventilator. Which symptom indicates increased intracranial pressure?
Increased respirations.
Widened pulse pressure.
Prolonged capillary refill.
Decreased blood pressure.
The Correct Answer is B
Choice A rationale:
Increased respirations are not a specific symptom of increased intracranial pressure (ICP). They might occur due to other respiratory or metabolic issues.
Choice B rationale:
Widened pulse pressure (the difference between systolic and diastolic blood pressure) is a sign of increased ICP. It results from increased systolic pressure due to the body's attempt to compensate for the rising pressure within the skull.
Choice C rationale:
Prolonged capillary refill is indicative of decreased peripheral perfusion or shock, which can be caused by various factors but is not directly related to ICP.
Choice D rationale:
Decreased blood pressure is not a consistent symptom of increased ICP. In fact, widened pulse pressure is more characteristic.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Pedal edema is not indicative of digoxin toxicity. Digoxin toxicity primarily affects the heart's electrical activity and rhythm, not fluid accumulation in the extremities.
Choice B rationale:
Cardiac arrhythmias are a hallmark sign of digoxin toxicity. Digoxin can lead to various types of arrhythmias, such as atrial tachycardia, atrial fibrillation, and ventricular ectopy. This occurs due to the drug's effects on altering the electrical conduction in the heart.
Choice C rationale:
Circumoral cyanosis is not a typical sign of digoxin toxicity. This symptom might be seen in conditions like methemoglobinemia or respiratory distress, but it's not directly related to digoxin toxicity.
Choice D rationale:
Infrequent voiding is not a specific sign of digoxin toxicity. It could be related to various factors, such as fluid intake, renal function, or underlying medical conditions, but it's not a hallmark of digoxin toxicity.
Correct Answer is B
Explanation
Minimize crying.
Choice A rationale:
Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.
Choice B rationale:
Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.
Choice C rationale:
Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.
Choice D rationale:
Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.
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