The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air

T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air

T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air

T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Answer and Explanation

The Correct Answer is B

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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Correct Answer is ["1.3"]

Explanation

To calculate the dosage of clindamycin, first convert the patient's weight from pounds to kilograms, knowing that 1 kg equals 2.2 lbs. The patient weighs 88 lbs, which is equivalent to 40 kg (88 lbs / 2.2 lbs per kg). The prescribed dose is 10 mg/kg/day, so the patient requires 400 mg/day (10 mg/kg * 40 kg). Since the medication is to be administered in two divided doses, each dose will be half of the daily requirement, resulting in 200 mg per dose. The medication is supplied at a concentration of 150 mg/mL, so to find out how many milliliters per dose, divide the dose in milligrams by the concentration: 200 mg / 150 mg/mL, which equals 1.33 mL. Rounded to the nearest tenth, the nurse will administer 1.3 mL per dose.

A. was found facedown in water for unknown length of time. B. has had multiple concussions in a short period of time. C. was in an assault resulting in a basilar skull fracture. D. suffered an epidural hematoma.

Correct Answer is A

Explanation

A. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.

B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.

C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.

D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.

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The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

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Naxlex Comprehensive Predictor Exams

A physician prescribes clindamycin 10 mg/kg/day IV in two divided doses for respiratory tract infection. The medication is supplied 150 mg/mL. The patient weighs 88 lbs. How much will the nurse administer per dose? (round to the nearest tenth)

Correct Answer is ["1.3"]

Explanation

The nurse is caring for several patients in the Intensive Care Unit. Which of the following patients is at greatest risk of anoxic brain injury? A patient who:

Correct Answer is A

Explanation

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