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

ATI LPN

ATI NCLEX PN Predictor Test

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

A. Monitor for changes in level of consciousness
B. Check for pupil dilation
C. Assess for bradycardia
D. Monitor for vomiting

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 discharge instructions with the parent of an infant who has rotavirus. Which of the following statements by the parent indicates an understanding of the teaching?

A. I will avoid feeding my baby for 12 hours
B. I will apply diaper cream during each diaper change
C. I will give my baby water between feedings
D. I will apply warm compresses for my baby's comfort

Correct answer: B

Rationale: The correct answer is B. Applying diaper cream during each diaper change is important to prevent skin breakdown in infants with rotavirus. Rotavirus can cause diarrhea, which can lead to skin irritation. Avoiding feeding the baby for 12 hours (choice A) can lead to dehydration and is not appropriate. Giving water between feedings (choice C) can further contribute to dehydration. Applying warm compresses (choice D) may provide comfort but does not address the specific issue of preventing skin breakdown associated with rotavirus.

3. Which intervention should be included for a client with heart failure?

A. Encourage increased fluid intake
B. Weigh the client daily to monitor fluid balance
C. Restrict fluid intake during meals
D. Limit daily activity to prevent fatigue

Correct answer: B

Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.

4. A client expresses doubt about the benefits of surgery. Which response by the nurse is most appropriate?

A. Ask the client to explain why they believe the surgery won't help.
B. Comment on the client's doubt regarding the procedure's benefits.
C. Assure the client that everything will be fine.
D. Acknowledge the client's uncertainty about the surgery.

Correct answer: D

Rationale: Option D is the most appropriate response as it acknowledges the client's expressed uncertainty about the surgery. By acknowledging the client's feelings, the nurse validates their concerns and opens the door for further discussion. This approach can help build trust and rapport with the client. Option A focuses more on seeking justification for the client's belief rather than addressing the underlying emotion. Option B, while acknowledging doubt, does not directly address the client's feelings. Option C, although well-intentioned, dismisses the client's concerns without exploring them further.

5. Which of the following situations can be identified as an ethical dilemma?

A. A nurse demonstrates signs of chemical impairment
B. A family has conflicting feelings about tube feeding for their terminally ill father
C. A nurse overhears a colleague threatening to restrain a patient if they do not stay in bed
D. A client with terminal cancer hesitates to name their spouse as power of attorney

Correct answer: B

Rationale: The correct answer is B. Ethical dilemmas involve conflicting values or feelings. In this situation, the family is conflicted about tube feeding for their terminally ill father, which presents a moral and ethical challenge. Choices A, C, and D do not represent ethical dilemmas. Choice A involves a nurse's impairment, which is a different issue. Choice C involves a nurse's observation of a colleague's threat, which is a patient safety concern. Choice D involves a client's hesitation in naming a spouse as power of attorney, which is a legal and decision-making issue, not necessarily an ethical dilemma.