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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Increased intracranial pressure (ICP) typically causes hypertension (increased blood pressure) rather than hypotension.
B. A decreased level of consciousness is one of the hallmark signs of increased ICP, as pressure on the brainstem affects consciousness.
C. Tachypnea may occur with ICP, but it is less specific compared to decreased consciousness.
D. This can occur with brain injury but is not as directly indicative of ICP as decreased consciousness.

A. Manifestations preceded by a severe headache B. Gradual onset of several hours C. History of neurologic deficits lasting less than 1 hr D. Maintains consciousness

Correct Answer is A

Explanation

A. A hemorrhagic stroke, especially after a ruptured cerebral aneurysm, often presents with a sudden, severe headache. This headache is typically described as the "worst headache of my life."
B. Gradual onset of several hours is more typical of an ischemic stroke, not a hemorrhagic stroke.
C. History of neurologic deficits lasting less than 1 hour would suggest a transient ischemic attack (TIA), not a hemorrhagic stroke.
D. Maintains consciousness is not typical of a hemorrhagic stroke, as the client may lose consciousness or be altered in their mental status due to the bleeding.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is B

Explanation

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

Which method of measurement is the gold standard for obtaining intracranial pressures?

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

Which intervention would the nurse implement to provide relief of the patient's discomfort when presenting to the clinic with a red, swollen, circumscribed, acutely, tender area near the eye and in the lid margin?

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed- head injury. Which of the following actions should the nurse take?

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan?