A patient with increased intracranial pressure after a traumatic brain injury is demonstrating an irregular breathing pattern, a slower heart rate, and a rising systolic blood pressure
Which of the following should the nurse suspect is occurring with this patient? 1. brain herniation
2. stroke in evolution
3. myocardial infarction
4. acute renal failure
1
Rationale: When herniation is occurring, the nurse will see drastic deterioration patterns in the patient's neurologic status and vital signs. The classic vital sign changes are called Cushing's triad, which consists of bradycardia, severe hypertension with a widened pulse pressure, and irregular breathing. These same symptoms may or may not be assessed if the patient is experiencing a stroke in evolution. These are not necessarily signs of a myocardial infarction. There is not enough information to determine if the patient is demonstrating acute renal failure.
You might also like to view...
The nurse is caring for a client who had an amputation of the left leg above the knee. What position can the nurse place the client in several times per day to promote stump extension and prevent contractures?
A) Supine B) Left lateral C) Prone D) Right lateral
An adult child who has brought the client in to be evaluated has been told the client has Alzheimer's disease. The adult child asks the nurse if all the children of the client are going to get the disease
The nurse responds that which of the following is the greatest risk factor for the development of Alzheimer's disease? 1. Age 2. Genetic predisposition 3. History of previous head injury 4. Environmental exposure
When documenting client care, the nurse understands that the most important reason for correct and accurate documentation is which of the following?
A) Legal representation to care B) Conveyance of information C) Assisting in organization of care D) Noting the client's response to interventions
A client with a history of violence begins to lose control of his anger, and a nurse decides that an intervention is warranted. The client cannot be "talked down," and he refuses medication. Which is the most appropriate nursing intervention?
A) Call for assistance from the assault team. B) Ask the ward clerk to put in a call for the physician. C) Make the client go to his room. D) Tell the client that if he does not calm down, he will be placed in restraints.