Which of these measures is appropriate for a patient diagnosed with increased intracranial pressure?
Suction every 2 hours.
Provide rest periods between nursing procedures.
Encourage active range of motion.
Assign the patient to a semiprivate room near the nurse's station.
The Correct Answer is B
Choice A reason: Suctioning every 2 hours is not appropriate for a patient with increased intracranial pressure (ICP). Suctioning can increase ICP due to the stress and stimulation it causes. It should only be performed when absolutely necessary and with proper precautions to minimize ICP spikes.
Choice B reason: Providing rest periods between nursing procedures is the correct measure. This helps minimize stimulation and stress, which can increase ICP. Rest periods allow the patient to stabilize and reduce the risk of further increasing the pressure within the skull.
Choice C reason: Encouraging active range of motion exercises is not suitable for a patient with increased ICP. Physical activity can exacerbate the condition by increasing intracranial pressure. The focus should be on minimizing activity and stress to prevent further elevation of ICP.
Choice D reason: Assigning the patient to a semiprivate room near the nurse's station is not the best approach. Patients with increased ICP require a quiet and calm environment to help manage their condition. A semiprivate room near the nurse's station may expose the patient to more noise and activity, which could increase ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E","F"]
Explanation
Choice A reason: Fever is a common sign of acute pancreatitis and indicates an inflammatory response. Inflammation of the pancreas can trigger the release of cytokines and other inflammatory mediators, leading to an elevated body temperature. This is a common symptom observed in many cases of acute pancreatitis and suggests an ongoing inflammatory process.
Choice B reason: Gray-blue discoloration of the flank or umbilical area, also known as Grey Turner's sign and Cullen's sign respectively, indicates bleeding and severe inflammation within the pancreas. These signs are indicative of retroperitoneal hemorrhage or pancreatic necrosis, which are severe complications of acute pancreatitis. The presence of such discoloration is a significant finding that suggests a more serious form of the condition.
Choice C reason: Hypertension is not typically associated with acute pancreatitis. In fact, patients with acute pancreatitis are more likely to experience hypotension due to fluid shifts, inflammatory responses, and potential hemorrhage. Monitoring blood pressure is important in these patients to manage any potential complications.
Choice D reason: Decreased amylase level is not an expected finding in acute pancreatitis. Typically, acute pancreatitis is associated with elevated levels of pancreatic enzymes such as amylase and lipase due to inflammation and damage to the pancreatic cells, which release these enzymes into the bloodstream.
Choice E reason: Nausea and vomiting are common symptoms in acute pancreatitis. The inflammation of the pancreas and the associated pain can stimulate the vomiting center in the brain and lead to nausea and vomiting. These symptoms are often severe and can significantly affect the patient's comfort and hydration status.
Choice F reason: Severe abdominal pain is one of the hallmark signs of acute pancreatitis. The pain is typically located in the upper abdomen and may radiate to the back. It is often described as constant and severe, and can be exacerbated by eating or lying flat. Effective pain management is a critical aspect of caring for patients with acute pancreatitis.
Correct Answer is A
Explanation
Choice A reason: The regulation of water balance by the kidneys involves maintaining the appropriate volume and concentration of body fluids. By taking daily weights, nurses can assess fluid retention or loss, while monitoring intake and output (I&O) helps track fluid balance. Specific gravity measures the concentration of urine, which provides information about the kidneys' ability to concentrate or dilute urine. These interventions directly relate to the kidneys' role in regulating water balance.
Choice B reason: Regulation of acid-base balance by the kidneys involves maintaining the proper pH levels in the blood through excretion or retention of hydrogen ions and bicarbonate. While important, this function is not the primary focus of interventions like daily weights, I&O, and specific gravity monitoring, which are more related to water balance.
Choice C reason: The regulation of blood pressure by the kidneys is achieved through the renin-angiotensin-aldosterone system, which controls blood volume and systemic vascular resistance. Although fluid balance can indirectly affect blood pressure, the specific interventions mentioned are more directly related to water balance than blood pressure regulation.
Choice D reason: Regulation of metabolic wastes involves the kidneys filtering and excreting waste products from the blood. This function is vital for overall health, but interventions like daily weights, I&O, and specific gravity monitoring are more focused on assessing fluid balance rather than directly measuring waste elimination.
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