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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Evening is not the best time to visit the patient with myasthenia gravis to help with bathing and exercising. Myasthenia gravis is a condition that causes muscle weakness and fatigue, which worsens as the day progresses. Therefore, the patient may have more difficulty performing these activities in the evening.
Choice B reason: Mid-afternoon is not the best time to visit the patient with myasthenia gravis to help with bathing and exercising. Myasthenia gravis causes muscle weakness and fatigue, which may be aggravated by the heat and humidity of the afternoon. Therefore, the patient may have more difficulty performing these activities in the mid-afternoon.
Choice C reason: Morning is the best time to visit the patient with myasthenia gravis to help with bathing and exercising. Myasthenia gravis causes muscle weakness and fatigue, which are less severe in the morning after a night of rest. Therefore, the patient may have more strength and energy to perform these activities in the morning.
Choice D reason: Before bedtime is not the best time to visit the patient with myasthenia gravis to help with bathing and exercising. Myasthenia gravis causes muscle weakness and fatigue, which are most severe at the end of the day. Therefore, the patient may have more difficulty performing these activities before bedtime.
Correct Answer is A
Explanation
Choice A reason: Patient should increase daily iron supplements, is a statement that indicates a need for additional teaching. Iron supplements are not recommended for patients with beta-thalassemia, because they already have high levels of iron in their blood due to the frequent blood transfusions. Excess iron can cause damage to the liver, heart, and other organs. Therefore, the patient should avoid iron supplements and foods rich in iron, and take chelation therapy to remove the excess iron from the body.
Choice B reason: Signs and symptoms of infection, is a statement that does not indicate a need for additional teaching. Patients with beta-thalassemia are at risk of developing infections, due to the impaired immune system and the exposure to blood-borne pathogens. Therefore, the patient should be aware of the signs and symptoms of infection, such as fever, chills, sore throat, cough, or skin lesions, and seek medical attention promptly.
Choice C reason: Our child will need to have blood transfusions, is a statement that does not indicate a need for additional teaching. Blood transfusions are the main treatment for patients with beta-thalassemia, because they help to increase the level of hemoglobin and red blood cells, and prevent anemia and its complications. Therefore, the patient should receive regular blood transfusions, usually every two to four weeks, depending on the severity of the condition.
Choice D reason: Swimming is a good activity for our child, is a statement that does not indicate a need for additional teaching. Swimming is a good activity for patients with beta-thalassemia, because it helps to improve the cardiovascular fitness, muscle strength, and joint mobility, and reduce the stress and fatigue. Therefore, the patient should engage in moderate physical activities, such as swimming, walking, or cycling, as tolerated, and avoid strenuous or competitive sports that can cause injury or dehydration.
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