The LPN/LVN is assisting the RN in providing care for a patient with a risk for increased ICP. What finding needs to be reported to the RN?
Shallow, even respirations
Narrowing pulse pressure
Increased systolic blood pressure
Pulse of 98
The Correct Answer is B
A. Shallow, even respirations may be a normal finding or indicate respiratory distress, but it is not a specific sign of increased ICP. It should still be monitored, but it is not the most concerning finding in this scenario.
B. Narrowing pulse pressure, which is the difference between systolic and diastolic blood pressure, is a sign of increased intracranial pressure (ICP). As ICP rises, the body compensates by increasing systolic blood pressure and decreasing diastolic pressure, leading to a narrowing pulse pressure. This is a critical sign that should be reported immediately to the RN.
C. Increased systolic blood pressure is a compensatory mechanism to maintain cerebral perfusion when ICP increases. While it is concerning, it is not as immediately alarming as narrowing pulse pressure, which is a more direct indicator of increased ICP.
D. A pulse of 98 is within normal limits for most adults and does not indicate any immediate concern regarding increased ICP. It should be monitored, but it does not require urgent reporting to the RN.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Kernig's sign is positive when there is pain and resistance to extending the leg at the knee when the hip is flexed, and Brudzinski's sign is positive when the client involuntarily flexes their knees and hips when the neck is flexed. These are both signs of meningeal irritation, which is characteristic of meningitis.
B. The patellar reflex is a deep tendon reflex that assesses the function of the L2-L4 spinal nerves. It is not specific to meningitis and would not be a primary indicator.
C. The pupillary reflex assesses the response of the pupils to light and is not specific to meningitis. It can be affected by various neurological conditions, but it is not a primary sign of meningitis.
D. Blumberg's sign is associated with peritonitis and indicates rebound tenderness in the abdomen. It is not related to meningitis, which affects the central nervous system rather than the abdominal cavity.
Correct Answer is A
Explanation
A. Delirium is an acute, temporary state of confusion, often caused by factors such as dehydration, infection, or metabolic disturbances. In this case, the elderly client’s confusion following vomiting and not eating or drinking for 2 days suggests that dehydration or an underlying illness is likely causing the delirium.
B. Alzheimer's disease is a progressive, degenerative condition that leads to chronic memory loss and cognitive decline. It does not typically cause sudden confusion, as seen in this case.
C. Huntington's disease is a genetic neurodegenerative disorder that causes motor dysfunction and cognitive decline. It does not present suddenly with confusion in an elderly client.
D. Parkinson's disease is a progressive neurological disorder that primarily affects motor function, causing tremors, rigidity, and bradykinesia. It does not typically present with sudden confusion or the symptoms described in this case.
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