what are the early signs of increased intracranial pressure iicp

ATI RN

ATI Capstone Adult Medical Surgical Assessment 2

1. What are the early signs of increased intracranial pressure (IICP)?

A. Restlessness, irritability, and confusion
B. Sudden onset of seizures
C. Decreased heart rate and pupillary response
D. Loss of consciousness

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. A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?

A. I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league.
B. I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running.
C. I'm so upset that this happened to me. What did I do to deserve this?
D. I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family.

Correct answer: A

Rationale: Choice A is the correct answer because it shows that the client has accepted their disability and is looking towards the future with realistic goals. This positive attitude and focus on engaging in activities that are achievable despite the disability indicate effective coping mechanisms. Choice B is incorrect as it reflects denial of the permanent nature of the disability. Choice C is incorrect as it shows feelings of anger and possible self-blame, which are not indicative of effective coping. Choice D is incorrect as it demonstrates a sense of hopelessness and self-perceived burden, which are signs of maladaptive coping.

3. What ECG changes are seen in hypokalemia?

A. Flattened T waves on the ECG
B. Elevated ST segments on the ECG
C. Widened QRS complex
D. Prominent U waves on the ECG

Correct answer: A

Rationale: The correct answer is A: Flattened T waves on the ECG. Flattened T waves are an early indicator of hypokalemia on an ECG. Choice B, Elevated ST segments, is not typically seen in hypokalemia but can be a sign of myocardial infarction. Choice C, Widened QRS complex, is more commonly associated with hyperkalemia. Choice D, Prominent U waves, is typically associated with hypokalemia, but flattened T waves are considered a more specific and early sign.

4. What intervention is needed when continuous bubbling is observed in the chest tube water seal chamber?

A. Tighten the connections of the chest tube system
B. Clamp the chest tube
C. Replace the chest tube system
D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the correct intervention is to tighten the connections of the chest tube system. This can help resolve an air leak that is causing the continuous bubbling. Clamping the chest tube or replacing the entire chest tube system are not appropriate interventions in this scenario. Clamping the tube can lead to a dangerous buildup of pressure, while replacing the chest tube system may not be necessary if the issue can be resolved by simply tightening the connections. Continuing to monitor the chest tube without taking corrective action may lead to complications associated with the air leak.

5. What are the common manifestations of a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Severe headache and confusion
D. Seizures and convulsions

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. A thrombotic stroke is characterized by a gradual onset of symptoms due to interrupted blood flow in the brain. This interruption results in manifestations such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache, confusion, seizures, and convulsions are more commonly associated with conditions other than thrombotic strokes.