Which of the following statements made by a nurse reflects the best understanding of the symptomology of increasing intracranial pressure (IICP)?
1. "If a client shows drowsiness or restlessness, I get concerned.".
2. "The primary focus is the client's pupils.".
3. "Acute muscle weakness, regardless of how severe, is a red flag.".
4. "When the client reports a headache, I know we have a problem.".
"If a client shows drowsiness or restlessness, I get concerned.".
Rationale: Alterations in the patient's level of consciousness (LOC) are usually the first sign of impending increase in ICP. While changes to pupil size and reactivity and decreased motor strength are signs of possible IICP, they are usually preceded by a change in the client's LOC. Headaches are generally not a specific indication of IICP.
Step of the Nursing Process: Assessment
You might also like to view...
A client is receiving pravastatin. The nurse understands that which of the following should be avoided with this client to prevent the risk of myopathy? Select all that apply
A) Quinapril (Accupril) B) Niacin (Niaspan) C) Clarithromycin (Biaxin) D) Albuterol (Proventil E) Verapamil (Calan)
A patient, being treated for thrombocytopenia, is not responding to therapy. The nurse realizes that which of the following might be indicated for this patient?
1. bone marrow transplant 2. blood transfusion 3. intravenous fluids 4. splenectomy
The initial descent of the fetus into the pelvis to zero station is considered which cardinal movements of labor?
A) Flexion B) Engagement C) Extension D) Expulsion
In human beings, the physiologic response to a stressor includes the
A) Sympathetic nervous system slowing the heart rate B) Hypothalamus secreting adrenocorticotropic hormone C) Hypothalamus secreting thyroid-stimulating hormone D) Epinephrine increasing the blood-glucose level