The nurse suspects that a patient is experiencing increasing intracranial pressure. What observations did the nurse make to come to this conclusion? (Select all that apply.)
a. Headache
b. Rising temperature
c. Decreasing systolic pressure
d. Dilated pupil on affected side
e. Decreasing level of consciousness (LOC)
ANS: A, B, D, E
Headache, increasing systolic pressure, decreasing LOC, dilated pupil on affected side, and rising temperature are all signs of increased ICP. C. Decreasing systolic blood pressure is not associated with increased intracranial pressure.
You might also like to view...
The nurse auscultates a blowing sound resembling a cardiac murmur in the mid- abdomen of a patient. The nurse describes this finding as
A) hyperactive bowel sounds. B) systolic bruit. C) venous hum. D) friction rub.
In reviewing information related to the occurrence of pregnancies using a focus group discussion with women, concern was expressed that many of them had problems using their respective type of contraception and, as a result, became pregnant
Based on this information, the nurse would incorporate which of the following in a teaching plan for group members? a. Provide information relative to product recalls of contraceptive devices. b. Have the clients keep a contraceptive diary related to the consistency of using methods because it is apparent that they forgot to use their preferred method as directed. c. Have the clients consider switching to a different form of contraception because the contraception did not prevent pregnancy for them. d. Plan for assessing the clients' knowledge related to the contraception methods and provide information to increase the knowledge base so that the effectiveness rate would improve.
The client's LDL cholesterol one year ago was 165 mg/dL. Through lifestyle changes, the client's current LDL cholesterol level is 122 mg/dL. How much has the client reduced their risk of developing cardiovascular disease? Round to a whole number
What will be an ideal response?
When working with a client with a somatization disorder, which is the most appropriate nursing intervention?
A) Avoiding discussion of physical symptoms B) Allowing the client to freely explore the meaning of the physical symptoms C) Confronting the client on the validity of the physical symptoms D) Gradually limiting the focus on physical symptoms