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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 A

Explanation

A. Yogurt or buttermilk: Cefdinir can disrupt the normal balance of bacteria in the gut. Yogurt or buttermilk, which contain probiotics, can help restore beneficial bacteria and reduce the risk of gastrointestinal complications such as antibiotic-associated diarrhea.

B. Avocados and cheese: While these are healthy foods, they do not specifically support gut health in the same way that probiotics do. Additionally, cheese may be high in fat and could potentially exacerbate gastrointestinal discomfort.

C. Fresh fruits: Fresh fruits provide important vitamins and fiber, but they do not specifically target the restoration of normal gut flora. Some fruits may also be difficult for a client with a postoperative wound infection to tolerate, especially if they are experiencing digestive issues.

D. Green leafy vegetables: While green leafy vegetables are nutritious, they do not have a direct role in supporting gut flora during antibiotic therapy. They are rich in vitamins and minerals, but the focus should be on probiotics like yogurt or buttermilk.

A. Hydrocortisone. B. Regular insulin. C. Broad spectrum antibiotic. D. Potassium chloride.

Correct Answer is A

Explanation

A. Hydrocortisone: Addison’s disease is characterized by insufficient cortisol production. The client’s symptoms, including weakness, confusion, and dehydration, along with laboratory values indicating low sodium, low glucose, and elevated potassium, suggest an adrenal crisis. Hydrocortisone is the primary.

B. Regular insulin: Regular insulin is used to lower blood glucose levels, but the client’s glucose level is already low, not high. Insulin could worsen the client's hypoglycemia. The focus should be on correcting the cortisol deficiency rather than administering insulin.

C. Broad spectrum antibiotic: While antibiotics may be needed if there’s a concern for infection, there’s no evidence of active infection here. The priority is addressing the client's Addisonian crisis, which is primarily treated with hydrocortisone, not antibiotics.

D. Potassium chloride: The client's potassium is elevated (5.3 mEq/L), but potassium chloride is not indicated in this case. The priority is to manage the underlying adrenal crisis, which will address the electrolyte imbalance.

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

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Correct Answer is A

Explanation

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Explanation

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