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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Avoid straining at stool, bending, or lifting heavy objects: These activities can increase intraocular pressure and disrupt healing of the surgical site after cataract extraction. The client should be taught to avoid anything that could strain the eye and risk complications like hemorrhage or wound dehiscence.
B. Irrigate conjunctiva with ophthalmic saline prior to instilling antibiotic ointment:
Routine irrigation is not required and may introduce additional risk. Clients are instructed on proper hand hygiene and drop instillation rather than conjunctival irrigation.
C. Do not read without direct lighting for 6 weeks: While good lighting helps reduce eye strain, reading in lower light does not delay healing after cataract surgery. This instruction is unnecessary and could limit the client’s ability to resume normal activities.
D. Limit exposure to sunlight during the first 2 weeks when the cornea is healing: Although bright light can be uncomfortable post-surgery, wearing sunglasses typically offers sufficient protection. There is no requirement to restrict sunlight exposure completely.
Correct Answer is B
Explanation
A. "You didn't do anything wrong.” This statement is well-intended, but may minimize the parent’s emotional experience. It’s important to acknowledge the parent’s feelings rather than just reassuring them. This response does not invite further expression of their emotions.
B. "This must be a very difficult time for you." This response acknowledges the parent's emotional distress and validates their feelings, creating an opportunity for them to express their concerns. It provides emotional support and opens the door for further discussion.
C. "Is there any particular reason why you think this is your fault?" While it may be important to understand the parent’s concerns, this response is confrontational. It may inadvertently make the parent feel blamed, which could worsen their state instead of comfort.
D. "With surgery, your baby should have a full recovery." This response may give false hope and oversimplifies the complexities of myelomeningocele. Recovery outcomes depend on various factors. The focus should be on providing emotional support rather than making promises.
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