The nurse is caring for a patient with a head injury after a fall from a ladder. The nurse must evaluate the patient for which signs and symptoms of increased intracranial pressure?

Lethargy

Slowed responses to verbal cues.

Negative Babinski sign

Altered speech.

Decreased level of consciousness.

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Lethargy is a sign of increased intracranial pressure (ICP), as it indicates a decreased level of alertness and responsiveness due to brain compression¹².
Choice B reason: Slowed responses to verbal cues are a sign of increased ICP, as they indicate a decreased level of cognitive function and communication ability due to brain compression¹².
Choice C reason: Negative Babinski sign is not a sign of increased ICP, as it indicates a normal reflex response of the toes to stimulation of the sole of the foot³. A positive Babinski sign, where the big toe extends upward and the other toes fan out, is a sign of neurological damage, but not necessarily increased ICP³.
Choice D reason: Altered speech is a sign of increased ICP, as it indicates a decreased level of language function and articulation due to brain compression¹².
Choice E reason: Decreased level of consciousness is a sign of increased ICP, as it indicates a decreased level of awareness and arousal due to brain compression¹².

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Correct Answer is A

Explanation

Choice A reason: Maintaining pressure to the puncture site and observing for drainage is the priority nursing intervention for a patient who had a lumbar puncture. It helps to prevent bleeding, hematoma, and cerebrospinal fluid leakage, which can cause complications such as infection, headache, or nerve damage.

Choice B reason: Completing a pain assessment and administering an ordered analgesic, as needed, is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause mild to moderate pain and discomfort at the puncture site, which can be relieved by analgesics, ice packs, or massage.

Choice C reason: Informing the patient they may feel pressure and sharp pain in their lower back for several hours is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause transient sensations of pressure and pain in the lower back, which can be reduced by lying flat, avoiding sudden movements, and drinking fluids.

Choice D reason: Assessing pulses distal to the lumbar puncture site every two hours is not an appropriate nursing intervention for a patient who had a lumbar puncture. Lumbar puncture does not affect the blood circulation to the lower extremities, unless there is a complication such as hematoma or nerve compression. Therefore, the nurse should monitor the neurological status, vital signs, and signs of infection or bleeding.

A. Presence of a synthetic silicone mesh stent in a coronary artery. B. Allergy to shellfish and iodine. C. Contact lenses. D. Presence of an internal insulin pump in the abdomen.

Correct Answer is D

Explanation

Choice A reason: Presence of a synthetic silicone mesh stent in a coronary artery is not a contraindication for MRI. Silicone is a non-magnetic material that does not interfere with the magnetic field or cause any harm to the patient or the device.

Choice B reason: Allergy to shellfish and iodine is not a contraindication for MRI. Shellfish and iodine are not related to the contrast agent used for MRI, which is usually gadolinium. However, the patient should inform the provider if they have any history of allergic reactions to contrast agents or any other medications.

Choice C reason: Contact lenses are not a contraindication for MRI. Contact lenses are made of plastic or silicone, which are non-magnetic materials that do not interfere with the magnetic field or cause any harm to the patient or the device. However, the patient should remove them before the procedure to avoid any discomfort or irritation.

Choice D reason: Presence of an internal insulin pump in the abdomen is a contraindication for MRI. Insulin pumps are electronic devices that contain metal parts, batteries, and wires, which can be affected by the magnetic field and cause malfunction, damage, or injury to the patient or the device. Therefore, the patient should inform the provider and the MRI technician about the insulin pump and follow their instructions on how to manage it before, during, and after the procedure.

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The nurse is caring for a patient with a head injury after a fall from a ladder. The nurse must evaluate the patient for which signs and symptoms of increased intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient undergoing a lumbar puncture by the provider. Select the priority nursing intervention the nurse would complete after the procedure.

Correct Answer is A

Explanation

The nurse completes a focused assessment and history of a patient who is scheduled for magnetic resonance imaging (MRI). Which data shared by the patient would the nurse need to contact the provider?

Correct Answer is D

Explanation

The home health nurse visits a patient with multiple sclerosis who complains of severe fatigue. Select the nurse's best suggestion to help decrease their symptom of fatigue.

The nurse is caring for a patient with a head injury after a fall from a ladder. The nurse must evaluate the patient for which signs and symptoms of increased intracranial pressure?

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