Exhibits
Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.
Course breath sounds
Irritability
Seizure activity
Decreased level of consciousness
Bradycardia
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}
Coarse breath sounds are typically associated with respiratory distress, indicating fluid or secretions in the airways.
Irritability can be a sign of both cerebral edema and respiratory distress as it may stem from hypoxia or increased intracranial pressure.
Seizure activity is more specifically related to cerebral edema, which can increase intracranial pressure and provoke seizures.
Decreased level of consciousness can occur in both conditions: cerebral edema (due to increased intracranial pressure) and respiratory distress (due to hypoxia).
Bradycardia is more indicative of cerebral edema, especially when associated with increased intracranial pressure and resultant autonomic dysregulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Extending progressive ambulation over one week is important but not the most critical instruction. Postoperative mobility is generally encouraged in a gradual manner, but it is not as urgent as managing specific activity restrictions.
B. Notifying the clinic if the child begins bedwetting is not typically a primary concern immediately following surgery for cryptorchidism. Bedwetting is not directly related to the surgical procedure or its common postoperative concerns.
C. Restricting the child from playing on riding toys is the most important instruction for preventing complications. Riding toys can be a safety risk due to potential trauma to the surgical site and could cause harm during the recovery period.
D. Supervising toileting to prevent picking at sutures is relevant but less critical compared to the need to restrict potentially harmful activities. While important, it is a secondary concern compared to overall activity restrictions.
Correct Answer is ["B","E","G"]
Explanation
A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up
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