When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?
Check the equipment.
Continue the assessment because no actions are indicated at this time.
Document the reading because it reflects that the treatment has been effective.
Contact the health care provider to review the care plan.
The Correct Answer is A
Choice A rationale
The nurse should check the equipment first when an ICP reading of 0 mm Hg is noted, as this may indicate equipment malfunction. An accurate ICP reading is critical for assessing and managing intracranial pressure to ensure the client's safety.
Choice B rationale
Continuing the assessment without checking the equipment may lead to incorrect conclusions based on a potentially faulty reading. It’s crucial to ensure the accuracy of the equipment before proceeding.
Choice C rationale
Documenting the reading as an effective treatment outcome without verifying its accuracy can be dangerous. An ICP reading of 0 mm Hg is unusual and warrants equipment verification.
Choice D rationale
Contacting the health care provider to review the care plan is premature until the equipment has been checked to rule out a false reading, ensuring the nurse provides accurate information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Increased intracranial pressure can result from various conditions, including brain injuries, tumors, or infections. However, decerebrate posturing is specifically associated with brain stem dysfunction rather than increased intracranial pressure alone.
Choice B rationale
Dysfunction in the cerebrum can lead to different posturing responses, such as decorticate posturing, which involves abnormal flexion of the arms. Decerebrate posturing, on the other hand, indicates more severe damage lower in the brain stem.
Choice C rationale
Dysfunction in the brain stem is indicated by decerebrate posturing, which involves extension and outward rotation of the arms and legs in response to painful stimuli. This type of posturing signifies serious damage to the brain stem and carries a poor prognosis.
Choice D rationale
Dysfunction in the spinal column may result in various neurological deficits but does not specifically cause decerebrate posturing. This type of posturing is indicative of brain stem damage rather than spinal column issues.
Correct Answer is C
Explanation
Choice A rationale
The largest area of the body without hair is not selected as it is not necessary for the graft to be hairless. The primary concern is matching the color and texture, not the absence of hair.
Choice B rationale
Any area that is not normally visible is not ideal as visibility is not the primary concern. The donor site needs to match the surgical site in color and texture to ensure a natural appearance.
Choice C rationale
An area matching the color and texture of the skin at the surgical site is selected to ensure the graft blends well with the surrounding skin and appears natural once healed.
Choice D rationale
An area matching the sensory capability of the skin at the surgical site is not typically a concern in graft selection. The focus is on the appearance and integration of the graft.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.