what are the key signs of increased intracranial pressure icp that a nurse should monitor for
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Nursing Elites

ATI LPN

ATI NCLEX PN Predictor Test

1. What are the key signs of increased intracranial pressure (ICP) that a nurse should monitor for?

Correct answer: A

Rationale: The correct answer is A: 'Monitor for changes in the level of consciousness.' Key signs of increased intracranial pressure (ICP) include changes in the level of consciousness and pupil dilation. Assessing for bradycardia and monitoring for vomiting are not typically considered primary signs of increased ICP. While bradycardia and vomiting can occur with increased ICP, they are not as specific or sensitive as changes in consciousness and pupil dilation.

2. What are the key differences between systolic and diastolic heart failure?

Correct answer: A

Rationale: The correct answer is A. Systolic heart failure is characterized by reduced ejection fraction, meaning the heart is not pumping effectively. Diastolic heart failure, on the other hand, is characterized by preserved ejection fraction, indicating that the heart has difficulty relaxing and filling properly. Choices B, C, and D are incorrect because they do not accurately describe the key differences between systolic and diastolic heart failure.

3. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the plan of care?

Correct answer: B

Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps improve oxygenation by preventing airway collapse, slowing down the breathing rate, and promoting better gas exchange. Administering oxygen at 2L/min via nasal cannula is not the first-line intervention as it can cause oxygen toxicity in COPD patients. Positioning the client in high Fowler's position may improve ventilation but does not specifically address the breathing technique required for COPD. Encouraging deep breathing and coughing is generally not recommended for clients with COPD as it can lead to air trapping and increased work of breathing.

4. Which assessment finding is expected with myxedema?

Correct answer: B

Rationale: Myxedema is characterized by a decreased metabolic rate, leading to manifestations such as decreased temperature. Therefore, the correct assessment finding expected with myxedema is a decreased temperature. Choices A, C, and D are incorrect because myxedema typically presents with a decreased pulse rate, not an increased pulse rate, absence of fine tremors (which are more common in hyperthyroidism), and weight gain rather than weight loss.

5. A nurse at a long-term care facility is part of a team preparing a report on the quality of care at the facility. Which of the following information should the nurse recommend including in the report to demonstrate improvement in care quality?

Correct answer: B

Rationale: The correct answer is B: '12% fewer urinary tract infections.' Tracking infections, such as UTIs, is crucial in assessing care quality improvements as the reduction in infections indicates better infection control practices and overall quality of care. Choices A, C, and D are incorrect. Increased admissions (Choice A) do not directly reflect improvements in care quality. Increased mortality rate (Choice C) is a negative outcome and demonstrates a decline in care quality. No changes in staffing (Choice D) do not provide direct evidence of care quality improvements.

Similar Questions

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A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
When providing discharge instructions for a client prescribed home oxygen, what is an essential safety measure?
A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?

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