The patient's ICP reading has gradually climbed from 15 to 23 mm Hg. The nurse's primary action is to:
a. drain off 7 mm of CSF from the catheter.
b. notify the physician.
c. place the patient in a high Fowler position to decrease the pressure.
d. check level of consciousness.
B
Under normal physiologic conditions, mean intracranial pressure (ICP) is maintained below 15 mm Hg. An increase in ICP can decrease blood flow to the brain, causing brain damage. Persistent ICP elevation above 20 mm Hg remains the most significant factor associated with a fatal outcome.
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To assess the Babinski's reflex of a 12-month-old infant, you stroke the plantar surface of the foot with the tip of your thumbnail from the lateral heel upward. A normal response is
a. all toes curling down. b. toes curling down and dorsiflexion of the great toe. c. toes fanning outward with dorsiflexion of the great toe. d. toes fanning outward with plantar flexion of the great toe.
Parents of a child recently diagnosed with Down syndrome relate to the nurse that they "feel guilty about causing the condition.". The best response by the nurse is:
1. "Down syndrome is a condition caused by an extra chromosome, and it really is not known why it occurs.". 2. "Down syndrome is a condition that is genetically transmitted from both the father and the mother.". 3. "Down syndrome is a condition that is carried on the X chromosome, so it came from the mother.". 4. "Down syndrome is caused by birth trauma, not by genetics.".
The nurse is providing teaching for a patient
who is to receive estrogen replacement therapy. Which statement is correct to include in the teaching session? a. "If you miss a dose, double-up on the next dose." b. "There's no need to be concerned about breast lumps or bumps that occur." c. "Be sure to report any weight gain of 5 pounds or more per week." d. "Take the medication on an empty stomach to enhance absorption."
A client has weakness of the left arm and hand after a stroke. Which is the best nursing intervention to help maintain the client's self-esteem during feeding?
1. Delegate feeding to minimize the amount of food spilled. 2. Encourage the client with self-feeding as much as possible. 3. Ensure that all foods come mechanically altered to take by straw. 4. Collaborate with speech therapy to improve client communication.