Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)?
A. Tachycardia
Tachycardia is not an indication of increased ICP, but rather a compensatory mechanism to maintain cerebral perfusion pressure in response to elevated ICP. As the ICP rises, the heart ratewill eventually decrease due to increased vagal stimulation from increased intrathoracic pressure. This choice is incorrect.
B. Restlessness
Restlessness is an early sign of increased ICP, indicating decreased cerebral oxygenation and impaired cognition. The nurse should monitor the client's level of consciousness and report any changes to the provider promptly. This choice is correct.
C. Hypotension
Hypotension is not an indication of increased ICP, but rather a sign of shock or hemorrhage that can lead to decreased cerebral perfusion pressure and brain ischemia. The nurse shouldmonitor the client's blood pressure and report any hypotension to the provider immediately. This choice is incorrect.
D. Amnesia
Amnesia is not an indication of increased ICP, but rather a result of brain injury that affects memory and learning. The nurse should assess the client's orientation and recall and provide frequent reminders and cues to enhance memory retention. This choice is incorrect.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Similar Questions
After explaining the procedure for an electroencephalograph, which of the following statements by the client indicates teaching was not effective?
A. Electrodes will be placed on the scalp
Electrodes will be placed on the scalp. This is correct because electrodes are attached to the scalp with adhesive or a cap to record the electrical activity of the brain during anelectroencephalograph.
B. There is a risk of electric shock
There is a risk of electric shock. This is incorrect because there is no risk of electric shock during an electroencephalograph. The electrodes only record the brain waves, they do not send any current to the brain.
C. Antiseizure medications must be withheld
Antiseizure medications must be withheld. This is correct because antiseizure medications can alter the results of an electroencephalograph. The client may need to stop taking them for a few days before the test, depending on the doctor's instructions.
D. Responses to light and noise will be recorded
Responses to light and noise will be recorded. This is correct because someelectroencephalographs involve stimulating the brain with light or sound to see how it reacts. The client may be asked to open and close their eyes, breathe deeply, or listen to noises during the test.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
A. Bradycardia
Bradycardia is not a common finding in meningitis. The client is more likely to have tachycardia due to fever and inflammation. This choice is incorrect.
B. Blurred vision
Blurred vision is not a specific sign of meningitis. It can be caused by many other conditions, such as eye strain, dry eyes, or refractive errors. This choice is incorrect.
C. Oriented to person, place, and year
Oriented to person, place, and year is a normal finding that indicates intact cognitive function.The client with meningitis may have altered mental status, confusion, or disorientation due to increased intracranial pressure and cerebral edema. This choice is incorrect.
D. Severe headache
Severe headache is a characteristic symptom of meningitis, caused by the irritation of the meninges and nerve endings by the infectious agent and inflammatory response. This choice is correct.
A nurse caring for a client who had a rightsided stroke and is exhibiting homonymous hemlanopsia when eating. Which of the following actions should the nurse take?
A. Encourage the use of the wide grip utensils.
Encouraging the use of wide grip utensils may be helpful for clients with impaired fine motor skills or hand weakness, but it does not address the issue of homonymous hemianopsia, which is a loss of vision in half of the visual field on the same side in both eyes. This choice is incorrect.
B. Remind the client to look for food on the left side of the tray
Reminding the client to look for food on the left side of the tray can help compensate for the loss of vision on the right side due to homonymous hemianopsia. The nurse should also place food and utensils on the left side and orient the client to their location before eating. This choice is correct.
C. Provide a nonskid mat to alleviate plate movement
Providing a nonskid mat to alleviate plate movement may prevent spills and accidents, but it does not help the client with homonymous hemianopsia to see the food on the right side of the tray. This choice is incorrect.
D. Encourage the client to use his right hand when feeding himself
Encouraging the client to use his right hand when feeding himself may be appropriate for clients with leftsided weakness or paralysis due to stroke, but it does not address the visualimpairment caused by homonymous hemianopsia. This choice is incorrect.