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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.
Choice B rationale
Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.
Choice C rationale
Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.
Choice D rationale
Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.
Correct Answer is C
Explanation
Choice A rationale
The peripheral nervous system (PNS) consists of all the nerves outside the brain and spinal cord. It transmits signals to and from the central nervous system but does not specifically regulate energy expenditure.
Choice B rationale
The parasympathetic nervous system is part of the autonomic nervous system that promotes "rest and digest" functions, conserving energy by slowing the heart rate and increasing intestinal and gland activity.
Choice C rationale
The sympathetic nervous system is responsible for the "fight or flight" response, which prepares the body to expend energy rapidly in response to perceived threats. It increases heart rate, dilates airways, and mobilizes energy stores.
Choice D rationale
The central nervous system (CNS) consists of the brain and spinal cord. It is responsible for processing information and coordinating bodily functions but does not specifically regulate energy expenditure.
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