Your patient is a 30-year-old female who fell indoors and landed on her head while using a ladder to reach for something that was high up on a shelf.
The patient has developed massive bleeding in the brain. Which of the following signs would be the MOST consistent with a brain herniation?
Defecation.
Pinpoint pupils.
Tachycardia.
Bilateral dilated pupils.
The Correct Answer is D
Choice A rationale
Defecation, while it can occur during severe neurological events due to autonomic dysregulation, is a non-specific sign and not a primary or direct indicator of brain herniation. Brain herniation primarily affects vital centers and cranial nerves, leading to more direct neurological compromise.
Choice B rationale
Pinpoint pupils are typically associated with pontine lesions or opioid overdose due to parasympathetic overactivity. In contrast, brain herniation, especially uncal herniation, often causes ipsilateral pupil dilation due to compression of the oculomotor nerve (cranial nerve III), leading to parasympathetic blockade.
Choice C rationale
Tachycardia, an increased heart rate, can be a non-specific response to stress, pain, or hypovolemia. In the context of brain herniation, as intracranial pressure rises and compresses the brainstem, bradycardia (slowing of the heart rate) is a more characteristic finding due to the Cushing reflex, not tachycardia.
Choice D rationale
Bilateral dilated pupils, especially when fixed and non-reactive to light, are a critical and often late sign of severe brain herniation, indicating significant brainstem compression and widespread damage, particularly to the midbrain's oculomotor nerve nuclei or their pathways. This signifies severe cerebral anoxia or irreversible brain injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Respiratory acidosis is characterized by a low pH and an elevated PaCO2. In this scenario, the pH is elevated (7.57), indicating alkalosis, and the PaCO2 (37 mmHg) is within the normal range, not elevated. Therefore, this option is inconsistent with the provided ABG results.
Choice B rationale
Metabolic acidosis is characterized by a low pH and a low bicarbonate level. The patient's pH is elevated (7.57), signifying alkalosis, and the bicarbonate (30 mEq/L) is elevated. These findings contradict the definition of metabolic acidosis.
Choice C rationale
The pH of 7.57 is significantly elevated, indicating alkalosis. The bicarbonate (HCO3) level of 30 mEq/L is elevated above the normal range (22-26 mEq/L), which directly accounts for the alkalosis. The PaCO2 of 37 mmHg is within the normal range (35-45 mmHg), indicating no respiratory compensation has occurred. This complete lack of respiratory compensation points to uncompensated metabolic alkalosis. The loss of gastric acid through the NGT contributes to this condition.
Choice D rationale
Respiratory acidosis is characterized by a low pH and an elevated PaCO2. Here, the pH is high (alkalotic) and the PaCO2 is within normal limits. Thus, this option does not match the observed blood gas values.
Correct Answer is B
Explanation
Choice A rationale
Administering bicarbonate would address the metabolic component if it were present, but the primary issue here is respiratory acidosis, indicated by the elevated CO2 and low pH. Bicarbonate could worsen the respiratory acidosis by shifting the equilibrium and further depressing respiratory drive in some cases. Normal HCO3 is 22-26 mEq/L.
Choice B rationale
The ABGs indicate respiratory acidosis (pH 7.24, CO2 68 mmHg, HCO3 25 mEq/L). Increasing the respiratory rate and depth allows for greater CO2 exhalation, thereby decreasing the partial pressure of carbon dioxide (PCO2) and raising the pH back towards the physiological normal range of 7.35-7.45. Normal CO2 is 35-45 mmHg.
Choice C rationale
Morphine is an opioid that depresses the central nervous system, including the respiratory drive. Administering morphine would further exacerbate the existing respiratory acidosis by decreasing the patient's respiratory rate and depth, leading to even higher CO2 retention and a further drop in pH.
Choice D rationale
Decreasing the respiratory rate and depth would worsen the patient's hypercapnia, meaning an even higher CO2 level. This would further lower the pH, exacerbating the respiratory acidosis and potentially leading to more severe physiological compromise due to inadequate gas exchange and ventilation.
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