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 A
Explanation
Choice A rationale:
After undergoing cleft palate repair, it's appropriate to inform the mother that her child may want to be close to her most of the time. The child might feel more secure in the presence of their caregiver during the recovery period.
Choice B rationale:
Having the child sleep in the same bed is not typically recommended due to safety concerns, especially after surgery.
Choice C rationale:
Increased independence is not a common immediate response after hospitalization, especially for a young child recovering from surgery.
Choice D rationale:
While attention during hospitalization is important, it wouldn't necessarily translate to the need for stricter limits. Post-hospitalization care should focus on the child's comfort and recovery rather than punitive measures.
Correct Answer is B
Explanation
Choice A rationale:
Returning to the hospital if the child spits up blood is a correct response as it indicates the recognition of potential postoperative bleeding.
Choice B rationale:
Giving the child cherry gelatin, even though it's the child's favorite, might not be appropriate after a tonsillectomy/adenoidectomy, as certain foods can irritate the healing throat.
Choice C rationale:
Returning to the hospital if the child develops difficulty breathing is a necessary step to address any respiratory distress.
Choice D rationale:
Having the child rinse her mouth frequently with water to prevent a bad breath odor is a suitable suggestion to maintain oral hygiene and comfort after surgery. In all three scenarios, the rationale for the correct answers revolves around patient safety, comfort, and appropriate post-operative care. The incorrect choices in each question either introduce potential complications, misunderstandings, or actions that might compromise the patient's well-being.
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