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. A nurse is reinforcing teaching with a client about cancer prevention. The nurse should include that frequent consumption of which of the following foods increases the risk for developing cancer?

Correct answer: A

Rationale: The correct answer is A: Lamb. Lamb is high in saturated fat, which is linked to an increased risk of developing cancer. Choice B (Poultry) is a lean protein source and is not associated with an increased cancer risk. Choice C (Tuna) is a good source of omega-3 fatty acids, which have anti-inflammatory properties that may reduce cancer risk. Choice D (Beef) is also high in saturated fat like lamb, making it a poor choice for cancer prevention.

3. What are the signs and symptoms of fluid overload, and how should a nurse manage this condition?

Correct answer: A

Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.

4. A nurse is assessing a client who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?

Correct answer: D

Rationale: Correct! A calcium level of 8.0 mg/dL indicates hypocalcemia. Hypocalcemia can lead to increased neuromuscular excitability, manifesting as tingling of the extremities. Choices A, B, and C are incorrect findings associated with other electrolyte imbalances or conditions and are not typically related to hypocalcemia. Constipation is commonly seen in hypokalemia, absent deep-tendon reflexes are associated with hypermagnesemia, and nausea and vomiting are more indicative of hypercalcemia.

5. A client undergoing radiation therapy is being taught about skin care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because avoiding perfumed lotions is important to prevent skin irritation after radiation therapy. Using a heating pad (A) can further damage the skin, applying cold compresses (C) may not be recommended, and scrubbing the area daily with soap and water (D) can be too harsh on the skin, leading to further irritation and damage.

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