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 dietary recommendation should be given to a patient with pre-dialysis end-stage kidney disease?

Correct answer: A

Rationale: The correct dietary recommendation for a patient with pre-dialysis end-stage kidney disease is to limit phosphorus intake to 700 mg/day. Excess phosphorus can be harmful to individuals with kidney disease as their kidneys are not able to remove it effectively. Choice B is incorrect as increasing sodium intake is generally not recommended for individuals with kidney disease due to its association with high blood pressure. Choice C is also incorrect as protein restriction is a common recommendation for patients with advanced kidney disease, but the range provided is not accurate. Choice D is incorrect as eating three large meals per day may not be suitable for managing the condition.

3. What is the primary nursing action for a patient experiencing continuous bubbling in the chest tube water seal chamber?

Correct answer: A

Rationale: The correct answer is to tighten the connections of the chest tube system. Continuous bubbling in the chest tube water seal chamber indicates an air leak. By tightening the connections of the chest tube system, the nurse can often resolve the issue by ensuring there are no loose connections allowing air to enter. Clamping the chest tube or replacing the chest tube system are not appropriate actions in this situation. Clamping the tube can cause a dangerous buildup of pressure, while replacing the system should only be considered if tightening the connections does not resolve the air leak.

4. What is the priority action when the nurse administers insulin for a misread blood glucose reading?

Correct answer: A

Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.

5. What dietary changes should be implemented for a patient with GERD?

Correct answer: A

Rationale: The correct answer is A: Avoid mint and spicy foods. Patients with GERD should avoid mint and spicy foods because they can increase gastric acid production, exacerbating symptoms. Choice B is incorrect because eating large meals before bedtime can worsen GERD symptoms due to lying down with a full stomach. Choice C is incorrect as consuming liquids with meals can lead to increased pressure on the lower esophageal sphincter, promoting acid reflux. Choice D is also incorrect as drinking milk as a snack is not recommended for GERD patients, as it may temporarily soothe symptoms but can ultimately stimulate acid production.

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