Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Increased ICP

Decreased cerebral blood flow (CBF)

Increased cerebral perfusion pressure (CPP)

Normal intracranial pressure

Answer and Explanation

The Correct Answer is B

A.   Increased ICP would be a concern when the MAP falls below 70 mm Hg because reduced blood pressure can lead to inadequate cerebral blood flow and worsen ICP.
B.   Decreased cerebral blood flow (CBF) is also a concern with low MAP, but the priority is maintaining MAP at a sufficient level to ensure adequate perfusion.
C.   Increased CPP is unlikely with a low MAP, as CPP is a product of MAP and ICP.
D.   Normal ICP would be a good outcome; however, with a low MAP, the nurse should be concerned about insufficient cerebral perfusion and the risk of increased ICP.

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Correct Answer is D

Explanation

A. Difficulty moving the upper extremities may occur in some stroke patients but is not a direct complication of immobility.
B. Stiffness in the lower extremities could be a result of immobility, but pressure ulcers are a higher immediate concern.
C. Difficulty hearing some types of sounds is unrelated to immobility.
D. Immobility increases the risk of pressure ulcers, especially over bony prominences like the sacrum. A reddened area indicates potential early tissue damage due to prolonged pressure.

A. Tachycardia B. Amnesia C. Restlessness D. Hypotension

Correct Answer is C

Explanation

A. Tachycardia is more commonly associated with early stages of shock or compensation but is not a specific sign of increased ICP.
B. Amnesia may occur with a traumatic brain injury, but it is not a direct sign of increased ICP.
C. Restlessness or agitation is an early sign of increased ICP, as the brain becomes more impaired due to pressure, leading to confusion and changes in behavior.
D. Hypotension is not typically associated with increased ICP. In fact, as ICP rises, there may be compensatory mechanisms that maintain blood pressure, and in later stages, the blood pressure may rise.

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Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is caring for an older adult client who had a stroke 4 weeks ago and who is unable to move independently. The nurse should monitor for which of the following complications of immobility?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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