The nurse is caring for a child who has sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse monitors for the earliest sign of increased ICP by assessing for:
1. Apnea
2. Posturing
3. Tachycardia
4. Changes in level of consciousness (LOC)
4
Rationale: An altered level of consciousness is an early sign of increased ICP. Late signs of in-creased ICP include tachycardia, leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.
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An elderly man diagnosed with Alzheimer's disease is being seen in the health clinic. The nurse observes the man brushing his hair with a toothbrush. This inability to process information would be documented as which of the following?
A) Anomia B) Agnosia C) Aphasia D) Apraxia
The care plan of an older adult patient states that the patient should be monitored while in the bathroom because of a history of vasovagal reflex. The nurse knows that she should as-sess for:
1. extremely elevated blood pressure after ambulation. 2. nausea and vomiting after a meal. 3. lightheadedness and fainting during defecation. 4. inability to urinate.
Which of the following individuals is likely to require more hours of sleep?
A) a 75 year old B) a 43 year old C) a 25 year old D) a 15 year old
A client is admitted to the emergency department after an automobile accident and
complains of a stiff neck. What vertebrae ensures that the head can turn freely? A) Atlas B) Axis C) Sacrum D) Coccyx