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Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

0800: Heart rate 130 beats/minute, blood pressure 190/90 mm Hg; 1200: heart rate 136 beats/minute, blood pressure 200/100 mm Hg, Kussmaul respirations.

0800: Heart rate 55 beats/minute, blood pressure 160/70 mm Hg; 1200: heart rate 50 beats/minute, blood pressure 194/70 mm Hg, irregular respirations.

0800: Heart rate 110 beats/minute, blood pressure 130/70 mm Hg; 1200: heart rate 100 beats/minute, blood pressure 110/70 mm Hg, shallow respirations.

0800: Heart rate 70 beats/minute, blood pressure 120/60 mm Hg; 1200: heart rate 100 beats/minute, blood pressure 90/60 mm Hg, rapid respirations.

Answer and Explanation

The Correct Answer is B

A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP.

B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting.

C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP.

D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.

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Correct Answer is ["5.6"]

Explanation

Rationale:

Convert the client's weight from pounds (lb) to kilograms (kg).

Weight in kg = 132 lb / 2.2 lb/kg

= 60 kg.

Calculate the desired dose per minute in micrograms (mcg).

Desired dose per minute (mcg/min) = Desired dose (mcg/kg/min) × Weight (kg)

= 5 mcg/kg/min × 60 kg

= 300 mcg/min.

Convert the desired dose from micrograms per minute (mcg/min) to milligrams per hour (mg/hr).

1 mg = 1000 mcg

1 hr = 60 min

Desired dose in mg/hr = (300 mcg/min / 1000 mcg/mg) × 60 min/hr

= 0.3 mg/min × 60 min/hr

= 18 mg/hr.

Determine the concentration of the available Dopamine solution in milligrams per milliliter (mg/mL).

Available concentration = Total medication (mg) / Total volume (mL)

= 1600 mg / 500 mL

= 3.2 mg/mL.

Calculate the IV pump rate in milliliters per hour (mL/hr).

IV pump rate (mL/hr) = Desired dose (mg/hr) / Available concentration (mg/mL)

= 18 mg/hr / 3.2 mg/mL

= 5.625 mL/hr.

Round the answer to the nearest tenth.

= 5.6

A. 1+ strength in left upper extremity B. Decreased range of motion C. Coolness of skin D. Reduced pulse distal to injury E. Pain with movement

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

Rationale:

1+ strength in left upper extremity: Reduced strength in the affected arm could indicate a humeral fracture, which can impair muscle function and strength. A rotator cuff injury could cause pain, but it doesn’t necessarily lead to a reduction in strength to the extent seen with a humeral fracture.
Decreased range of motion: Decreased range of motion is common with humeral fractures as the bone is likely immobilized and painful to move. A rotator cuff injury can also lead to decreased range of motion due to pain and limited ability to lift or rotate the arm.
Coolness of skin: Coolness to the skin could indicate poor circulation, which can occur if there is vascular injury related to a humeral fracture or if there is significant swelling causing compression of blood vessels.Coolness is less commonly associated with rotator cuff injuries unless there is concurrent trauma affecting blood flow.
Reduced pulse distal to injury: Reduced pulses can suggest vascular injury, which is more likely with a humeral fracture, especially if the bone fragments are displacing or compressing blood vessels.This is unlikely with a rotator cuff injury, as it primarily affects the tendons and muscles without significant impact on vascular structures.
Pain with movement: Pain with movement is a classic symptom of a fracture, particularly when moving the arm or shoulder area. Pain with movement is also a hallmark of a rotator cuff injury, especially when the arm is raised or rotated.

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Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["5.6"]

Explanation

Exhibits For each assessment finding, click to indicate whether the findings from the client's assessment are generally associated with rotator cuff injury and/or humeral fracture. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

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