what are the early signs of increased intracranial pressure iicp
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Nursing Elites

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

1. What are the early signs of increased intracranial pressure (IICP)?

Correct answer: A

Rationale: The correct answer is A: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These signs indicate that the brain is starting to experience pressure, often due to conditions such as trauma, tumors, or hemorrhage. Sudden onset of seizures (choice B) is not typically an early sign of IICP but can occur later as the pressure increases. Decreased heart rate and pupillary response (choice C) are more indicative of late-stage IICP as the brainstem becomes compromised. Loss of consciousness (choice D) is a late sign of IICP when the pressure has significantly increased and is causing significant brain dysfunction.

2. What medication should be administered first for wheezing due to an allergic reaction?

Correct answer: A

Rationale: The correct answer is A, Albuterol via nebulizer. Albuterol is the first-line treatment for wheezing caused by an allergic reaction because it quickly opens the airways by relaxing the muscles around the airways. Cromolyn (choice B) is used more for prevention rather than immediate relief of symptoms. Methylprednisolone (choice C) and Aminophylline (choice D) are not the first-line treatments for acute wheezing due to an allergic reaction.

3. A client at high risk for iron deficiency anemia should increase the consumption of which of the following foods?

Correct answer: C

Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, making them beneficial for a client at high risk for iron deficiency anemia. Yogurt (Choice A), apples (Choice B), and cheddar cheese (Choice D) are not significant sources of iron. Other iron-rich foods include dried fruits, red meat, and green leafy vegetables.

4. What does continuous bubbling in the chest tube water seal chamber indicate?

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system. This occurs when air is entering the system from the outside, preventing the lung from fully re-expanding. Choice B is incorrect because continuous bubbling is not a sign of normal chest tube function. Choice C is incorrect because a blocked chest tube would typically exhibit no bubbling or fluctuation in the water seal chamber. Choice D is incorrect as continuous drainage would not cause bubbling in the water seal chamber.

5. What signs indicate increased intracranial pressure (IICP)?

Correct answer: A

Rationale: Restlessness, irritability, and confusion are early signs of increased intracranial pressure (IICP). These symptoms occur due to the brain's increased pressure within the skull. Sudden onset of seizures (Choice B) is not typically associated with increased intracranial pressure. Bradycardia and altered pupil response (Choice C) are signs of advanced or worsening IICP. Loss of consciousness (Choice D) is a late sign of increased intracranial pressure.

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