Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma?

Narrowing pulse pressure, brachycardia, irregular heart rate

Stiff neck, bradycardia, narrowing pulse pressure

Bradycardia, irregular breathing, widening pulse pressure

Narrow pulse pressure, bradycardia, irregular respirations

Answer and Explanation

The Correct Answer is C

A. Narrowing pulse pressure, bradycardia, irregular heart rate: Narrowing pulse pressure is not characteristic of increasing ICP. ICP elevation typically causes widening pulse pressure, making this combination inconsistent with the classic signs of herniation.

B. Stiff neck, bradycardia, narrowing pulse pressure: While a stiff neck may indicate meningeal irritation, it is not a primary sign of rising ICP. Narrowing pulse pressure does not align with the hemodynamic changes seen in Cushing’s triad.

C. Bradycardia, irregular breathing, widening pulse pressure: The Cushing’s triad is the hallmark of increased ICP. It reflects the body’s response to maintain cerebral perfusion: systolic hypertension widening pulse pressure, bradycardia from baroreceptor reflex, and irregular respirations from brainstem compression.

D. Narrow pulse pressure, bradycardia, irregular respirations: Narrow pulse pressure is inconsistent with elevated ICP, which usually produces hypertension with a widened pulse pressure. The other signs may occur, but the combination does not match the classic presentation of ICP elevation.

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Correct Answer is C

Explanation

A. The client denies nausea or anorexia: While improved appetite is beneficial, it does not directly indicate that lactulose is effective. Lactulose is primarily used to reduce ammonia levels and prevent hepatic encephalopathy. Symptom relief alone does not confirm therapeutic effect.

B. The client's bilirubin level decreases: Lactulose does not directly affect bilirubin levels. Bilirubin reflects liver excretory function, not the medication’s action on ammonia. Changes in bilirubin are not a reliable measure of lactulose effectiveness.

C. The client is alert and oriented: Lactulose reduces blood ammonia by promoting its excretion via the gastrointestinal tract. Improved mental status, such as being alert and oriented, indicates effective reduction of ammonia and prevention of hepatic encephalopathy.

D. The client has at least one stool daily: While increased bowel movements are expected with lactulose, the frequency alone does not confirm that ammonia levels are adequately reduced. Stool output is a mechanism, not the ultimate therapeutic outcome.

A. Perform a halo test B. Instruct the client to blow his nose and check the nares for inflammation. C. Obtain a specimen of the fluid for culture and sensitivity. D. Check the nasal drainage for glucose.

Correct Answer is A

Explanation

A. Perform a halo test: Clear nasal drainage in a client with periorbital ecchymosis may indicate cerebrospinal fluid (CSF) leakage. The halo or ring test helps differentiate CSF from normal nasal secretions, which is critical for detecting a basilar skull fracture. Early identification guides further neurologic assessment and prevents complications.

B. Instruct the client to blow his nose and check the nares for inflammation: Blowing the nose can increase intracranial pressure and worsen CSF leakage. Assessing for inflammation does not confirm CSF presence and may be harmful in suspected skull fractures.

C. Obtain a specimen of the fluid for culture and sensitivity: Culturing the fluid is unnecessary initially and may delay urgent assessment. Identifying CSF leakage takes priority to prevent infection and guide immediate care.

D. Check the nasal drainage for glucose: Glucose testing can suggest CSF, but the halo test provides a more rapid and reliable bedside assessment. Confirming CSF leakage quickly is essential for early intervention.

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Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma?

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Correct Answer is A

Explanation

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