what signs indicate increased intracranial pressure iicp
Logo

Nursing Elites

ATI RN

ATI Capstone Medical Surgical Assessment 1 Quizlet

1. 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.

2. A patient reports abdominal cramping after enema administration. What is the appropriate action?

Correct answer: A

Rationale: Lowering the height of the enema solution container is the appropriate action when a patient reports abdominal cramping after enema administration. This helps reduce the flow rate of the solution, potentially alleviating the cramping. Stopping the procedure and removing tubing (Choice B) would be too abrupt and may not address the issue. Increasing the flow of enema solution (Choice C) could exacerbate the cramping by adding more pressure. Continuing the enema at a slower rate (Choice D) might not provide immediate relief compared to lowering the height of the solution container.

3. What should be the priority action when a patient is admitted with chest pain from acute coronary syndrome?

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This is the priority action in treating chest pain associated with acute coronary syndrome as it helps to dilate blood vessels, improve blood flow to the heart, and reduce cardiac tissue damage. Administering nitroglycerin is crucial in managing the symptoms and potential complications of acute coronary syndrome. Obtaining IV access (Choice B) is important for administering medications and fluids but does not address the immediate symptom of chest pain. Checking cardiac enzymes (Choice C) and administering aspirin (Choice D) are essential steps in the management of acute coronary syndrome, but they should follow the administration of nitroglycerin to address the immediate symptom and improve blood flow to the heart.

4. What are the expected symptoms in a patient with a thrombotic stroke?

Correct answer: A

Rationale: A thrombotic stroke typically presents with a gradual loss of function on one side of the body. This gradual onset distinguishes it from a hemorrhagic stroke, which often manifests with sudden and severe symptoms like loss of consciousness (choice B), severe headache and confusion (choice C), or loss of sensation in the affected limb (choice D). Therefore, choices B, C, and D are not typically associated with thrombotic strokes.

5. What are the early symptoms of compartment syndrome?

Correct answer: A

Rationale: The correct answer is A: 'Unrelieved pain, pallor, and pulselessness.' Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to reduced blood flow and potential tissue damage. Early symptoms include unrelieved pain (out of proportion to the injury), pallor (pale skin color), and pulselessness (decreased or absent pulses). Choices B, C, and D are incorrect as they do not represent the classic early symptoms of compartment syndrome.

Similar Questions

What are the manifestations of osteomyelitis?
What is a characteristic sign of hypokalemia on an ECG?
A patient reports abdominal cramping after enema administration. What action should the nurse take to relieve the discomfort?
What is an escharotomy, and why is it performed?
A client at high risk for iron deficiency anemia should increase the consumption of which of the following foods?

Access More Features

ATI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses