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

Answer and Explanation

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.

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Correct Answer is ["A","B","E"]

Explanation

A. Vasoconstrictors (Imitrex), such as sumatriptan, are commonly used to treat the headache stage of a migraine by constricting blood vessels, which helps alleviate the pain.

B. A dark, quiet environment is beneficial for migraine sufferers as bright lights and loud noises can exacerbate symptoms. Resting in a calm environment can help reduce discomfort.

C. While teaching relaxation is helpful for migraine prevention, it may not be effective in the acute phase of the headache. Relaxation techniques are more useful in managing triggers and reducing frequency.

D. Exercise is generally not recommended during the headache stage of a migraine, as it can worsen the pain. Light activity may help during the prodromal phase, but not during the headache itself.

E. Analgesics (NSAIDs) such as ibuprofen or naproxen are often used to relieve the pain during the headache stage of a migraine. They can help reduce inflammation and discomfort.

F. Teaching stress reduction is beneficial for preventing migraines but is not typically helpful during the headache stage itself. Stress management is more useful in the long term.

A. It must be hard to see your mother so ill and upset. B. If you just sit quietly with your mother, I'm sure she will calm down. C. I'll talk with your mother and see if I can comfort her. D. "Your mother's crying seems to bother you more than it does her."

Correct Answer is A

Explanation

A. It must be hard to see your mother so ill and upset is a compassionate and empathetic response that acknowledges the son's distress while validating his feelings. This approach fosters open communication and emotional support, which is important for both the patient and their family.

B. Telling the son to sit quietly with his mother may invalidate his feelings and suggests that the solution is simply to wait for the mother to calm down. It does not acknowledge his emotional distress or provide the necessary support.

C. While offering to comfort the mother is kind, this response does not address the son’s emotional needs. It is important to support the family members as well, not just the patient.

D. "Your mother's crying seems to bother you more than it does her" is dismissive of the son's feelings and could make him feel misunderstood or judged. It does not provide the necessary emotional support for the son.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When a client is in the headache stage of a migraine headache, which of the following may help the person cope with this stage? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a client who has hemiplegia following a stroke. The client's adult son is distressed over his mother's crying and condition. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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