When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

A rising systolic blood pressure

Change in mood or attention level

Irregular respiratory rate and depth

A bounding radial pulse

Answer and Explanation

The Correct Answer is B

A. A rising systolic blood pressure: While increased intracranial pressure can lead to changes in blood pressure, it is not typically the first sign observed. Changes in blood pressure may occur later in the progression of increased intracranial pressure.

B. Change in mood or attention level: Changes in mood, behavior, or level of consciousness are often early signs of increased intracranial pressure. These changes may include irritability, confusion, restlessness, or lethargy.

C. Irregular respiratory rate and depth: Respiratory changes such as irregular breathing patterns or Cheyne-Stokes respirations can occur with increased intracranial pressure, but they are not typically the first sign observed.

D. A bounding radial pulse: While changes in pulse rate or quality may occur with increased
intracranial pressure, a bounding radial pulse is not typically the first sign observed. It may occur later in the progression of increased intracranial pressure as compensation mechanisms fail.

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Correct Answer is B

Explanation

A. Monitor level of consciousness (LOC): While monitoring the patient's level of consciousness is important, administering medication to stop the seizure takes precedence to prevent potential complications associated with prolonged seizure activity.

B. Administer lorazepam (Ativan) 4 mg IV: The priority in managing continuous tonic-clonic seizures is to terminate the seizure activity promptly. Lorazepam is a benzodiazepine that can help to abort seizures and is often used as first-line treatment in the acute setting.

C. Obtain computed tomography (CT) scan: While obtaining diagnostic imaging such as a CT scan may be necessary to evaluate for underlying causes of the seizure, it is not the first
intervention in the acute management of continuous seizures. Stabilizing the patient and stopping the seizure activity take precedence.

D. Give phenytoin (Dilantin) 100 mg IV: Phenytoin is an antiepileptic medication that is used for long-term management of seizures but is not typically administered as first-line treatment during an acute seizure episode. Benzodiazepines like lorazepam are preferred for immediate seizure control.

A. Observe the client's ability to smile and frown. B. Instruct the client to look up and down without moving his head. C. Ask the client to shrug his shoulders against passive resistance. D. Have the client stand with eyes his closed and touch his nose.

Correct Answer is B

Explanation

A. Observe the client's ability to smile and frown: This assessment is related to cranial nerve VII (facial nerve), which controls facial expressions.
B. Instruct the client to look up and down without moving his head: Cranial nerve III (oculomotor nerve) controls eye movements, including upward and downward gaze. Asking the client to look up and down without moving the head assesses the function of this nerve.

C. Ask the client to shrug his shoulders against passive resistance: This assessment is related to cranial nerve XI (accessory nerve), which innervates the trapezius and sternocleidomastoid muscles involved in shoulder shrugging.

D. Have the client stand with eyes his closed and touch his nose: This assessment is part of the cerebellar function test and assesses coordination and proprioception but does not specifically assess cranial nerve III.

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When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

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Naxlex Comprehensive Predictor Exams

Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures?

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Correct Answer is B

Explanation

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