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.
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Related Questions
Correct Answer is D
Explanation
A. Emotional lability (rapid mood swings) can occur with brain injuries, but it is more commonly associated with damage to the frontal lobe, not the brainstem.
B. Personality changes are also more likely to result from damage to the frontal lobe or other areas of the brain responsible for behavior and personality, not the brainstem.
C. Diabetes insipidus can result from brain injury, particularly damage to the hypothalamus or pituitary gland, but it is not a direct consequence of brainstem injury.
D. Unstable vital signs are a common result of damage to the brainstem, which is responsible for regulating autonomic functions such as heart rate, blood pressure, and respiration. Damage to the brainstem can lead to life-threatening instability in these vital functions.
Correct Answer is B
Explanation
A. Limiting the client's physical activity is not recommended for clients with Parkinson's disease. Physical activity, including exercises to improve strength, balance, and flexibility, is essential to manage symptoms and maintain mobility.
B. Providing the client a cane is appropriate. A cane can help with balance and stability, especially as the client experiences motor symptoms such as rigidity and bradykinesia. It can reduce the risk of falls.
C. Offering the client 3 large meals a day is not ideal. Smaller, more frequent meals are recommended for clients with Parkinson's disease, as they may experience difficulty swallowing, digestion issues, or a reduced appetite.
D. Speaking loudly to the client is not necessary unless the client has difficulty hearing. It is more important to speak clearly and at a normal volume, as clients with Parkinson's disease may have issues with speech (e.g., soft or slurred speech).
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