When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated is :

Elevating the head of the bed 20 degrees

Cleansing the eyes every 4 hours with normal saline

Lubricating the skin with baby oil

Suctioning the oropharynx routinely

Answer and Explanation

The Correct Answer is D

Choice A reason : Elevating the head of the bed to 20 degrees can help reduce intracranial pressure by promoting venous drainage from the brain. It is a recommended practice unless contraindicated by other conditions³.

Choice B reason : Cleansing the eyes with normal saline every 4 hours is a standard care procedure to maintain eye hygiene and prevent infection, especially when the blink reflex may be compromised in an unconscious patient³.

Choice C reason : Lubricating the skin with baby oil is a common practice to prevent dryness and maintain skin integrity. It is not contraindicated unless the patient has specific allergies or skin conditions that require different care³.

Choice D reason : Suctioning the oropharynx routinely is contraindicated as it can stimulate the vagus nerve and potentially increase intracranial pressure. Suctioning should be performed cautiously and only when necessary³.

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Correct Answer is B

Explanation

Choice A reason : Heat intolerance is not a symptom associated with myxedema coma. Instead, patients with myxedema coma typically present with cold intolerance due to decreased metabolic rate and reduced heat production as a result of hypothyroidism¹.

Choice B reason : Facial edema, particularly around the eyes, is a characteristic finding in myxedema coma. This condition results from severe hypothyroidism, which can cause mucopolysaccharide deposition in the skin, leading to non-pitting edema¹.

Choice C reason : Tachycardia is not expected in myxedema coma; rather, bradycardia is more common due to the reduced metabolic demands of the body in the hypothyroid state¹.

Choice D reason : Diarrhea is not typically a symptom of myxedema coma. Patients are more likely to experience constipation due to slowed gastrointestinal motility in the context of hypothyroidism¹.

A. Hypervolemia B. Hypovolemia C. Hyponatremia D. Hyperkalemia

Correct Answer is A

Explanation

Choice A reason : In end-stage kidney disease, the kidneys are unable to excrete excess fluid, leading to fluid overload or hypervolemia. This condition can manifest as shortness of breath due to pulmonary edema, swelling in the lower extremities, and crackles in the lungs upon auscultation. Elevated blood pressure is also a common finding in hypervolemia due to the increased volume of fluid in the bloodstream⁵⁶⁷⁸.

Choice B reason : Hypovolemia, or decreased blood volume, is not consistent with the symptoms described. It typically presents with signs of dehydration, low blood pressure, and tachycardia, which are not mentioned in the client's manifestations.

Choice C reason : Hyponatremia, or low sodium levels in the blood, can occur in ESKD due to dilution from retained fluids, but the primary symptoms described by the client are more indicative of fluid overload rather than electrolyte imbalance alone.

Choice D reason : Hyperkalemia, or high potassium levels, is a serious complication of ESKD due to the kidneys' inability to excrete potassium. While it is a concern in ESKD, the symptoms described by the client are more directly related to fluid overload.

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When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated is :

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has myxedema coma. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?

A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?

A nurse is caring for an older adult client who has a WBC count of 2,000/mm^3^ after three rounds of chemotherapy. Which of the following actions should the nurse take?

A nurse is caring for a client with left-sided heart failure. To reduce fluid volume excess, which of the following should the nurse anticipate using?

A nurse is teaching a client about self-administered peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

A client is diagnosed with hypothyroidism. Which signs/symptoms should the nurse expect the client to exhibit?