A patient presents with stroke-like symptoms, increased intracranial pressure (ICP), and increased cerebral perfusion. What should be the priority nursing intervention for this patient?
Position the patient with the head of the bed elevated at 30 degrees to reduce ICP
Administer hypertonic saline to decrease cerebral edema and Increase CPP
Administer high-dose antihypertensive medications to lower cerebral perfusion pressure (CPP)
Perform a complete neurological assessment to assess for the level of consciousness and motor function
The Correct Answer is A
Rationale:
A. Position the patient with the head of the bed elevated at 30 degrees to reduce ICP is correct because elevating the head promotes venous drainage from the brain, which helps lower ICP while maintaining adequate cerebral perfusion pressure (CPP). This is a non-invasive, immediate, and effective nursing intervention to prevent further neurological deterioration in patients with increased ICP.
B. Administer hypertonic saline to decrease cerebral edema and increase CPP is partially correct because hypertonic saline is used to treat cerebral edema and maintain CPP, but it is typically administered after physician orders and as part of a medical plan. It is not the initial nursing action priority in this scenario.
C. Administer high-dose antihypertensive medications to lower CPP is incorrect because lowering CPP in a patient with stroke-like symptoms can decrease cerebral blood flow, worsening ischemia and neurological damage. CPP must be maintained within an optimal range to ensure brain perfusion.
D. Perform a complete neurological assessment to assess for the level of consciousness and motor function is important for ongoing monitoring and baseline data, but it is not the first priority when the patient is experiencing increased ICP. Immediate interventions to reduce ICP and prevent secondary brain injury take precedence.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
Rationale:
A. Full tonic-clonic seizure activity is correct because status epilepticus often involves generalized tonic-clonic seizures, which are the most recognizable and severe form of seizure activity. Continuous or repeated tonic-clonic activity can cause hypoxia, hypotension, and metabolic disturbances, making rapid intervention critical.
B. Seizure activity that lasts for 2 minutes or longer is incorrect because a seizure lasting 2 minutes is prolonged but does not meet the definition of status epilepticus, which typically requires a longer duration or repeated seizures without recovery.
C. Two or more sequential seizures occur without full recovery of consciousness between seizures is correct because status epilepticus can occur as repeated seizures without regaining consciousness, which is a defining characteristic. This pattern leads to cumulative neuronal injury and systemic complications.
D. Seizure activity that lasts for greater than 60 minutes is incorrect because the formal definition of status epilepticus does not require 60 minutes of continuous seizure activity. Intervention is indicated much earlier, usually after 5 minutes of continuous seizure activity, to prevent long-term neurological damage.
E. Seizure activity that lasts for 30 minutes or longer is correct because prolonged seizures ≥30 minutes are consistent with status epilepticus and pose significant risk for permanent brain injury. Modern definitions often use ≥5 minutes for initiation of treatment, but 30 minutes represents severe ongoing status epilepticus.
Correct Answer is B
Explanation
Rationale:
A. The liver is the primary organ for glycogen storage and gluconeogenesis, which maintain blood glucose during fasting or stress. In end-stage liver disease (ESLD), these processes are impaired due to hepatocellular dysfunction, resulting in low blood glucose levels. Hypoglycemia can contribute to weakness, confusion, or even hepatic encephalopathy, making it an expected clinical finding.
B. DIC is not typically associated with ESLD. DIC is a systemic disorder of clotting and fibrinolysis, leading to widespread microthrombi formation and simultaneous bleeding. While patients with ESLD do have coagulopathy due to impaired synthesis of clotting factors and thrombocytopenia, this does not cause the generalized activation of coagulation seen in DIC. If DIC were present in a patient with ESLD, it would usually indicate a secondary condition, such as sepsis, trauma, or severe infection, rather than the liver disease itself.
C. Ascites is a common and expected finding in ESLD, primarily caused by portal hypertension and hypoalbuminemia. Increased hydrostatic pressure in the portal circulation forces fluid into the peritoneal cavity, while low plasma oncotic pressure from reduced albumin worsens fluid accumulation. Patients may present with abdominal distension, shifting dullness, or fluid wave.
D. Malnutrition is frequent in ESLD due to decreased appetite, impaired nutrient absorption, altered metabolism, and early satiety from ascites. Patients often show muscle wasting, weight loss, vitamin deficiencies, and low protein levels.
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