Problem
Answer the following questions:
A. Identify causes of intracranial pressure.
B. Name three priority manifestations of an increase in intracranial pressure
C. Identify three nursing interventions related to client safety and intracranial pressure.
The family of a client with chronic hyponatremia asks if the water restriction is a punishment for the noncompliant behavior of the client. Which of the following is the nurse's best response?
• "No. Limiting fluid intake decreases the risk for kidney damage."
• "No. Limiting water intake will help decrease the episodes of vomiting for the patient."
• "No. Limiting fluid intake keeps the blood from becoming more dilute and possibly causing more health problems."
• "No. Limiting fluid decreases the patient's sense of thirst and prevents him from having the desire to drink liquids that contain a high amount of sodium."
A client receiving an insulin and glucose infusion for hyperkalemia has new lab results that reveal a serum potassium level of 4.7 mEq/L. Which of the following would be the first action by the nurse?
• Assess the respiratory status of the client and alert the Rapid Response Team.
• Stop the infusion and immediately begin a hetastarch infusion.
• Continue the infusion at an increased rate.
• Slow the infusion and notify the health care provider.
A nurse is taking the blood pressure of a client who is being treated for hypocalcemia. When the cuff is fully inflated, the nurse notes the client's hand moves to the palmar flexion position. When the cuff is deflated the hand sustains the position. Which of the following is the nurse's best first action?
• Apply oxygen.
• Check capillary refill ensuring it is less than 3 seconds.
• Slow the calcium-containing IV solution
• Elevate the extremity on pillows
A. What is the primary expected outcome for a client who has preeclampsia after magnesium sulfate is administered? What are toxic manifestations for this medications?
B. What manifestations indicate to a nurse that a client may become eclamptic?
C. Describe the condition that is a variant of gestational hypertension with hematological and hepatic manifestations.
D. For a client who has severe preeclampsia, what are priority maternal and fetal assessments?
A nurse is caring for a client who has pregnancy-induced hypertension. A prescription reads: "Infuse magnesium sulfate 2 g/hr IV. Increase to 3 g/hr when indicated." Which of the following assessments would indicate the need for a possible increase in dose?
• Urinary output 45 cc/hr
• Blood pressure remaining 124/70 mm Hg
• Deep-tendon reflexes increase from +2 to +4
• Client begins having regular contractions
A. Identify three manifestations of a child who is experiencing hyperactivity.
B. Identify two manifestations of impulsivity in children.