Question

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Answer 1

Correct Answers:

Decreased level of consciousness

Rationale :

🧠 Decreased level of consciousness is one of the earliest and most important signs of increased intracranial pressure (ICP).

🧠 After a traumatic brain injury, swelling, bleeding, or fluid accumulation can increase pressure inside the skull.

🧠 As ICP rises, cerebral perfusion decreases, which reduces oxygen delivery to brain tissue.

🧠 The client may become confused, restless, difficult to arouse, lethargic, or unresponsive as brain function worsens.

🧠 The nurse should monitor changes in Glasgow Coma Scale, orientation, pupil response, motor response, and vital signs closely.

Hypotension

🧠 Hypotension is not a typical early manifestation of increased ICP.

🧠 Increased ICP is more commonly associated with hypertension, especially when Cushing’s triad develops.

Bilateral weakness of extremities

🧠 Weakness can occur with neurological injury, but unilateral weakness is more commonly concerning for focal brain damage.

🧠 Bilateral weakness is not the most classic or priority early sign of increased ICP.

Tachypnea

🧠 Tachypnea is not the classic respiratory change associated with increased ICP.

🧠 Late increased ICP may cause irregular respirations, especially as brainstem compression worsens.

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Answer 2

Correct Answers:

Measure lactic acid level.
Obtain blood cultures.
Obtain a sputum culture.
Rapidly administer bolus of normal saline.
Obtain a UA.
Administer broad-spectrum antibiotics.

Rationale :

Measure lactic acid level

🔴 Lactic acid helps determine the severity of tissue hypoperfusion in sepsis.

🔴 A high lactate level suggests cells are not receiving enough oxygen, even if the oxygen saturation appears acceptable.

🔴 This client has signs of sepsis, including fever, tachycardia, tachypnea, hypotension, altered mental status, and infection source.

🔴 Measuring lactate early helps guide the urgency of treatment and the need for aggressive fluid resuscitation.

🔴 Lactate should be rechecked if initially elevated to evaluate response to therapy.

Obtain blood cultures

🟠 Blood cultures should be obtained before antibiotics when possible.

🟠 This helps identify the organism causing sepsis and guides later antibiotic adjustment.

🟠 Cultures should not delay antibiotic therapy if the client is unstable.

🟠 This client has a likely infected diabetic foot wound with purulent drainage, making bloodstream infection a concern.

🟠 Early cultures improve targeted treatment after initial broad-spectrum coverage is started.

Obtain a sputum culture

🟡 A sputum culture helps identify a respiratory source of infection.

🟡 This client has crackles in the lung bases, tachypnea, and oxygen saturation of 93% on oxygen.

🟡 These findings may suggest possible respiratory involvement or pneumonia contributing to sepsis.

🟡 Culturing suspected infection sources supports accurate diagnosis and antimicrobial narrowing.

🟡 Source identification is a key part of early sepsis management.

Rapidly administer bolus of normal saline

🟢 Rapid IV fluid administration helps restore intravascular volume and tissue perfusion.

🟢 This client has hypotension at 98/60 mm Hg, tachycardia, dry mucous membranes, and sepsis risk.

🟢 Sepsis causes vasodilation and capillary leakage, which can reduce effective circulating volume.

🟢 A bolus of isotonic crystalloid, such as normal saline, helps support blood pressure and organ perfusion.

🟢 Early fluids help reduce progression to septic shock.

Obtain a UA

🔵 A urinalysis helps assess for a urinary source of infection.

🔵 Older adults with infection can present with altered mental status rather than classic urinary symptoms.

🔵 Diabetes increases the risk for urinary tract infection and complicated infection.

🔵 Identifying all possible infection sources is important in sepsis management.

🔵 UA results can guide further testing, culture decisions, and antimicrobial therapy.

Administer broad-spectrum antibiotics

🟣 Broad-spectrum antibiotics are a priority in the first hour of sepsis treatment.

🟣 Early antibiotic therapy reduces bacterial load and helps prevent worsening organ dysfunction.

🟣 The client has a likely infection source from the purulent diabetic foot wound and systemic signs of sepsis.

🟣 Antibiotics should ideally be given after cultures are obtained, but treatment should not be significantly delayed.

🟣 Timely antibiotics are essential to prevent progression to septic shock.

Type and cross-match for 2 units of packed RBCs

⚫ This client’s hemoglobin is 15 g/dL and hematocrit is 45%, which do not indicate acute blood loss or need for transfusion.

⚫ Type and cross-match is not part of the immediate first-hour sepsis priority unless bleeding or severe anemia is present.

Insert a nasogastric tube

⚫ An NG tube is not a first-hour sepsis intervention for this client.

⚫ It may be used for bowel obstruction, gastric decompression, or severe vomiting, but it does not treat sepsis or prevent septic shock.

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Answer 3

Correct Answers:

Excessive thrombosis and bleeding

Rationale :

🔷 Disseminated intravascular coagulation (DIC) is a serious disorder where the clotting system becomes abnormally activated throughout the body.

🔷 This widespread clotting causes tiny clots to form in small blood vessels, leading to excessive thrombosis and impaired tissue perfusion.

🔷 As clotting continues, the body consumes large amounts of platelets and clotting factors.

🔷 Once these clotting components are depleted, the client begins to develop excessive bleeding, such as petechiae, bruising, oozing from IV sites, hematuria, or gastrointestinal bleeding.

🔷 DIC is dangerous because the client can experience both clot formation and uncontrolled bleeding at the same time.

Immediate sodium and fluid retention

🔷 Sodium and fluid retention are more commonly associated with heart failure, kidney disease, or endocrine disorders.

🔷 This does not describe the main problem in DIC, which involves abnormal clotting and bleeding.

Decreased potassium

🔷 Decreased potassium is not a defining manifestation of DIC.

🔷 DIC primarily affects coagulation, platelet consumption, fibrin formation, and bleeding risk.

Progressive increase in platelet production

🔷 In DIC, platelets are consumed faster than the body can replace them, causing thrombocytopenia.

🔷 The expected problem is platelet depletion, not progressive platelet production.

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Answer 4

Correct Answers:

1971

Rationale :

🟢The client’s fluid needs after burns are commonly calculated using the Parkland formula: 4 mL × body weight in kg × percent total body surface area burned.

🟢The client weighs 73 kg, and the burned areas include the face and entire left arm.

🟢Using the Rule of Nines, the face is 4.5% and one entire arm is 9%, giving a total burn size of 13.5%.

🟢4 × 73 × 13.5 = 3,942 mL for the first 24 hr.

🟢Half of the total amount is infused during the first 8 hr: 3,942 ÷ 2 = 1,971 mL.

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Answer 5

Correct Answers:

Oliguria

Rationale :

🔴 Oliguria, or decreased urine output, is an important manifestation of possible kidney transplant rejection.

🔴 When the transplanted kidney is rejected, inflammation and immune injury reduce the kidney’s ability to filter blood and produce urine.

🔴 A sudden decrease in urine output can indicate declining graft function and should be reported promptly.

🔴 Other rejection findings may include fever, graft tenderness, hypertension, weight gain, edema, and rising serum creatinine.

🔴 Because this client is only 2 weeks postoperative, acute rejection is a major concern and requires rapid intervention.

Weight loss

🔴 Kidney rejection is more often associated with weight gain due to fluid retention.

🔴 Weight loss does not strongly indicate acute transplant rejection.

Insomnia

🔴 Insomnia is not a specific sign of kidney transplant rejection.

🔴 It may occur due to stress, medication effects, pain, or hospitalization.

Temperature 36.1° C (97.0° F)

🔴 A temperature of 36.1° C is not fever and does not indicate infection or rejection.

🔴 Rejection is more concerning when the client develops an elevated temperature.

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Answer 6

Correct Answers:

Decrease edema in the brain.

Rationale :

🧠 An osmotic diuretic, such as mannitol, is used to reduce increased intracranial pressure.

🧠 The medication creates an osmotic gradient that pulls excess fluid from swollen brain tissue into the bloodstream.

🧠 Once the fluid moves into the vascular space, the kidneys excrete it through increased urine output.

🧠 This helps decrease cerebral edema, reduce pressure inside the skull, and support cerebral perfusion.

🧠 The nurse should monitor neurological status, urine output, serum osmolality, electrolytes, and signs of dehydration or fluid overload.

Increase edema in the brain

🧠 Increasing brain edema would worsen intracranial pressure and increase the risk of brain herniation.

🧠 Osmotic diuretics are used to reduce swelling, not increase it.

Provide fluid hydration

🧠 Osmotic diuretics increase urine output and can remove fluid from the body.

🧠 Their purpose is not hydration but reduction of cerebral swelling.

Increase cell size in the brain

🧠 Increasing brain cell size would worsen cerebral swelling and pressure.

🧠 Mannitol works by pulling water out of brain tissue, not into brain cells.

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Answer 7

Correct Answers:

Use a soft toothbrush.
Avoid high-impact activities.
Wear a medical alert bracelet.

Rationale :

Use a soft toothbrush

🟣 Anticoagulant therapy increases the client’s risk for bleeding, including bleeding from the gums.

🟣 A soft toothbrush reduces trauma to oral tissues during daily hygiene.

🟣 The client should avoid hard-bristled toothbrushes, aggressive flossing, and activities that can injure the gums.

🟣 Good oral care is still important because infection and inflammation can increase bleeding risk.

🟣 This recommendation helps the client maintain hygiene while reducing preventable bleeding.

Avoid high-impact activities

🟣 High-impact or contact activities increase the risk of falls, bruising, cuts, and internal bleeding.

🟣 Because anticoagulants reduce clot formation, even minor trauma can lead to prolonged or serious bleeding.

🟣 The client should choose safer low-impact activities such as walking, depending on provider guidance.

🟣 The client should also use protective equipment and avoid activities with a high risk for head injury.

🟣 This teaching is important because bleeding complications can occur even when the client feels well.

Wear a medical alert bracelet

🟣 A medical alert bracelet informs emergency personnel that the client is taking anticoagulant medication.

🟣 This is especially important if the client is unconscious, confused, or unable to explain their medication history.

🟣 The bracelet helps providers make safer decisions about procedures, injections, trauma care, and medication administration.

🟣 It also alerts clinicians to assess carefully for hidden bleeding after injury.

🟣 Wearing identification is a key safety measure for clients receiving long-term anticoagulant therapy.

Avoid acetaminophen

🟣 Acetaminophen is generally safer than aspirin or NSAIDs for pain relief because it has less effect on platelet function.

🟣 The client should still avoid excessive doses and consult the provider before frequent use.

Stop anticoagulant medication when your symptoms subside

🟣 Anticoagulants should never be stopped without provider approval.

🟣 Stopping early can increase the risk of recurrent clot formation and another pulmonary embolism.

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Answer 8

Correct Answers:

Amylase

Rationale :

🟡 Amylase is a pancreatic digestive enzyme that commonly rises during acute pancreatitis.

🟡 When the pancreas becomes inflamed, digestive enzymes leak into the bloodstream.

🟡 Elevated amylase supports the diagnosis, especially when paired with severe upper abdominal pain, nausea, vomiting, and abdominal tenderness.

🟡 Lipase is also commonly elevated and is often more specific for pancreatic injury, but amylase is the correct option listed.

🟡 The nurse should monitor for complications such as hypocalcemia, hyperglycemia, dehydration, shock, and respiratory distress.

Magnesium

🟡 Magnesium is not the primary laboratory marker used to diagnose acute pancreatitis.

🟡 It may be monitored during illness, but elevation is not the expected key finding.

Calcium

🟡 Calcium is often decreased in severe acute pancreatitis due to fat necrosis and calcium binding.

🟡 Elevated calcium is not the expected value in this question.

RBC count

🟡 RBC count is not the key diagnostic laboratory value for acute pancreatitis.

🟡 Pancreatic enzyme elevation is more directly related to pancreatic inflammation.

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Answer 9

Correct Answers:

Administer lactulose.

Rationale :

🔵 Lactulose is used to reduce ammonia levels in clients with hepatic encephalopathy.

🔵 In end-stage cirrhosis, the liver cannot effectively convert ammonia into urea for elimination.

🔵 Lactulose acidifies the colon and traps ammonia in the bowel so it can be excreted in stool.

🔵 As ammonia decreases, neurological symptoms such as confusion, lethargy, asterixis, and altered mental status may improve.

🔵 The nurse should monitor bowel movements because lactulose is often titrated to produce 2 to 3 soft stools daily.

Administer diuretics

🔵 Diuretics are used to manage ascites and fluid retention in cirrhosis.

🔵 They do not directly remove ammonia or treat hepatic encephalopathy.

Administer vitamin K

🔵 Vitamin K may help support clotting factor production when deficiency contributes to bleeding risk.

🔵 It does not lower ammonia levels or improve encephalopathy directly.

Limit fluid intake

🔵 Fluid restriction may be used for severe hyponatremia or fluid overload.

🔵 It does not directly decrease ammonia levels in hepatic encephalopathy.

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Answer 10

Correct Answers:

Stridor

Rationale :

🔴 Stridor is a high-pitched, harsh inspiratory sound that indicates narrowing or obstruction of the upper airway.

🔴 After endotracheal tube removal, stridor may occur from laryngeal edema, vocal cord swelling, or airway trauma.

🔴 This is a priority finding because swelling can progress quickly and compromise ventilation.

🔴 The nurse should report stridor immediately and be prepared for oxygen support, nebulized medications, corticosteroids, or possible reintubation.

🔴 Among the findings listed, stridor is the most urgent because it signals potential airway obstruction.

Sore throat

🔴 A sore throat is common after extubation due to irritation from the endotracheal tube.

🔴 It is usually expected and does not require urgent provider notification unless severe or worsening.

Copious oral secretions

🔴 Copious secretions require suctioning and close monitoring to maintain airway clearance.

🔴 They are not as immediately concerning as stridor unless the client cannot clear secretions or oxygenation worsens.

Hoarseness

🔴 Hoarseness is common after extubation due to vocal cord irritation.

🔴 It should be monitored, but stridor is more concerning because it suggests airway narrowing.

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QLexNursing

1 :
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

2 :
A nurse is caring for a 73-year-old client in the emergency department (ED).

Answer Options

3 :
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

4 :
A client who suffered burn injuries to their face and entire left arm is to receive lactated ringers. The client weighs 73 kg. How much fluid will be infused for the first 8 hours? (Round to the nearest whole number).

5 :
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

6 :
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

7 :
A nurse is providing discharge teaching to a client who has a pulmonary embolism and has begun anticoagulant therapy. Which of the following recommendations should the nurse make?(Select All that Apply.)

8 :
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

9 :
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

10 :
A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?

QLexNursing

1 : A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

2 : A nurse is caring for a 73-year-old client in the emergency department (ED).

Answer Options

3 : A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

4 : A client who suffered burn injuries to their face and entire left arm is to receive lactated ringers. The client weighs 73 kg. How much fluid will be infused for the first 8 hours? (Round to the nearest whole number).

5 : A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

6 : A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

7 : A nurse is providing discharge teaching to a client who has a pulmonary embolism and has begun anticoagulant therapy. Which of the following recommendations should the nurse make?(Select All that Apply.)

8 : A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

9 : A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

10 : A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?

1 :
A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

2 :
A nurse is caring for a 73-year-old client in the emergency department (ED).

3 :
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

4 :
A client who suffered burn injuries to their face and entire left arm is to receive lactated ringers. The client weighs 73 kg. How much fluid will be infused for the first 8 hours? (Round to the nearest whole number).

5 :
A nurse is assessing a client who is 2 weeks postoperative following a kidney transplant. Which of the following manifestations should the nurse identify as possible organ rejection?

6 :
A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

7 :
A nurse is providing discharge teaching to a client who has a pulmonary embolism and has begun anticoagulant therapy. Which of the following recommendations should the nurse make?(Select All that Apply.)

8 :
A nurse is reviewing the laboratory data of a client who has acute pancreatitis. The nurse should expect to find an elevation of which of following values?

9 :
A nurse is planning care for a client who has end-stage cirrhosis of the liver with encephalopathy. Which of the following interventions should the nurse plan to implement to decrease the client's ammonia level?

10 :
A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?