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 precaution should be advised to a patient following a cataract surgery?

Correct answer: A

Rationale: Following cataract surgery, patients are advised to wear dark glasses while outdoors. This is crucial to protect the eyes from bright light and prevent complications such as excessive glare or discomfort. Choice B, avoiding NSAIDs, is not directly related to post-cataract surgery care. Choices C and D, using warm compresses and applying cold packs, are not typically part of the standard post-operative care for cataract surgery.

3. What are the expected findings in a patient experiencing hypokalemia?

Correct answer: A

Rationale: The correct answer is A: Flattened T waves on an ECG. Hypokalemia is characterized by flattened T waves on an ECG, which is an early indicator of low potassium levels. Elevated ST segments (Choice B) are associated with conditions like myocardial infarction, not hypokalemia. Prominent U waves (Choice C) are typically seen in hypokalemia, but flattened T waves are more specific. Bradycardia (Choice D) can be a manifestation of severe hypokalemia but is not as specific as flattened T waves on an ECG.

4. What should the nurse do if a patient experiences abdominal cramping during enema administration?

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the solution container. This adjustment can help alleviate the cramping by reducing the speed and pressure of the solution entering the colon. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in extreme cases but is not the initial step. Continuing the enema at a slower rate (Choice D) may not effectively address the cramping, making it less optimal than lowering the height of the solution container.

5. What is the priority dietary modification for a patient with pre-dialysis end-stage kidney disease?

Correct answer: A

Rationale: The correct answer is A: Limit phosphorus intake to 700 mg/day. In patients with pre-dialysis end-stage kidney disease, restricting phosphorus intake is crucial to manage their condition. Excessive phosphorus can lead to mineral and bone disorders, which are common in kidney disease. Choice B, increasing potassium intake, is not the priority and can be harmful as kidney disease often leads to hyperkalemia. Choice C, eating three large meals per day, is not recommended as smaller, frequent meals are usually better tolerated. Choice D, restricting protein intake to 1 g/kg/day, is important in later stages of kidney disease but is not the priority at the pre-dialysis stage.

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