Nurse Think HEALTHCARE SYSTEM

Name: J.R. Age: 47 years

Health Care Provider: M. Starr MD

Allergies: iodine

MRN: 2557350128

Code Status: Full Code

Review the information in the electronic health record. Which client assessment data is anticipated by the nurse? Select all that apply

Tachycardia

Hypertension

Confusion

Decreased urinary output

Oxygen requirements decreasing

Answer and Explanation

Correct Answer : A,C,D

A. The nurse anticipates tachycardia due to the metabolic disturbances and physiological stress associated with acute renal failure. Elevated potassium levels (6.8 mEq/L) can irritate the myocardium, leading to compensatory heart rate increases or dysrhythmias. Additionally, the initial hypovolemia from the motorcycle accident triggers sympathetic nervous system activation, maintaining a high heart rate.

B. While renal disease can eventually lead to fluid retention, hypertension is not necessarily anticipated in the acute phase following severe hypovolemic shock. The client’s history of massive hemorrhage and hypovolemia from the accident suggests a risk for persistent hypotension or labile blood pressure.

C. Confusion is a frequent assessment finding in clients with advancing renal impairment and elevated nitrogenous wastes. The accumulation of urea (BUN 25 mg/dL) and other toxins crosses the blood-brain barrier, resulting in uremic encephalopathy. Metabolic acidosis, which often accompanies a low GFR of 51 mL/min/1.73 m2, further depresses the central nervous system.

D. Decreased urinary output is the hallmark clinical sign of AKI, reflecting a significant drop in renal perfusion and filtration capacity. With a GFR reduced to 51 mL/min/1.73 m2 and elevated creatinine of 2.0 mg/dL, the kidneys are unable to effectively excrete fluid. The client is likely in the oliguric phase, where the volume of urine produced is insufficient to maintain homeostasis.

E. There is no evidence in the record to suggest oxygen requirements would be decreasing; in fact, they may increase. The presence of an elevated WBC (11,500 mm3) and the stress of a spinal cord injury (T8 severance) increase metabolic demands. Furthermore, fluid overload from AKI can lead to pulmonary edema, which would worsen rather than improve oxygenation status.

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Correct Answer is D

Explanation

A. Sluggish pupillary response to light: Changes in pupillary response typically occur as increased intracranial pressure (ICP) progresses and cranial nerve III becomes compressed. This is a later sign and may indicate significant neurologic compromise.

B. Vomiting: Vomiting can result from increased ICP due to stimulation of the vomiting center in the medulla. However, it is a nonspecific symptom and often occurs after early neurologic changes.

C. Headache: Headache is a common symptom of elevated ICP caused by stretching of pain-sensitive structures in the meninges. While it may appear early, it is subjective and can be difficult to assess, especially in patients with altered consciousness.

D. Change in level of consciousness: Alteration in level of consciousness, such as confusion, restlessness, or drowsiness, is the earliest and most sensitive indicator of rising ICP. It reflects the brain’s response to pressure before overt focal neurologic deficits or cranial nerve changes occur.

A. Hypertension and narrowing pulse pressure. B. Elevated systolic blood pressure and bradycardia C. Hypotension and tachycardia. D. Hypotension and bradycardia.

Correct Answer is B

Explanation

A. Hypertension and narrowing pulse pressure: Increased intracranial pressure leads to a widening pulse pressure rather than a narrowing one. As ICP rises, systolic pressure increases while diastolic pressure may remain stable or decrease, producing a widened pulse pressure. Narrow pulse pressure is not characteristic of late ICP elevation.

B. Elevated systolic blood pressure and bradycardia: These are classic components of Cushing’s triad, a late and ominous sign of significantly increased ICP. Rising ICP decreases cerebral perfusion, triggering sympathetic-mediated hypertension to maintain blood flow. The resulting baroreceptor response causes reflex bradycardia, indicating brainstem involvement and impending herniation.

C. Hypotension and tachycardia: Hypotension and tachycardia are more consistent with hypovolemia or shock rather than increased ICP. In elevated ICP, the body attempts to preserve cerebral perfusion by increasing systemic blood pressure, not lowering it.

D. Hypotension and bradycardia: This combination does not reflect the compensatory physiologic response to increased ICP. Late ICP elevation is associated with systemic hypertension, not hypotension, as the body attempts to overcome reduced cerebral perfusion pressure.

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Nurse Think HEALTHCARE SYSTEM Name: J.R. Age: 47 years Health Care Provider: M. Starr MD Allergies: iodine MRN: 2557350128 Code Status: Full Code Review the information in the electronic health record. Which client assessment data is anticipated by the nurse? Select all that apply

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Naxlex Comprehensive Predictor Exams

When assessing a patient with a head injury, the nurse recognizes that which sign is the earliest indication of increased intracranial pressure?

Correct Answer is D

Explanation

When caring for a patient with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Correct Answer is B

Explanation

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Nurse Think HEALTHCARE SYSTEM

Name: J.R. Age: 47 years

Health Care Provider: M. Starr MD

Allergies: iodine

MRN: 2557350128

Code Status: Full Code

Review the information in the electronic health record. Which client assessment data is anticipated by the nurse? Select all that apply