ATI med surg QUESTIONS AND ANSWERS DOWNLOAD AND SCORE GRADE A/NURSING 325

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1.A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which of the following findings indicates that the client is experiencing increased ICP?a.Fla... t jugular veinsb.GCS score of 15c.Sleepiness exhibited by the clientd.Widening pulse pressuree.Decerebrate posturingf.Flat jugular veinsis incorrect. With increased ICP, the jugular veins are typically distended. A Glasgow Coma Scale score of 15is incorrect. A Glasgow Coma Scale score of 15 indicates neurological functioning within the expected reference range for eye opening, motor, and verbal response. Sleepiness exhibited by the clientis correct. Sleepiness or difficulty arousing the client from sleep is an indication of increased ICP. Widening pulse pressureis correct. A widening pulse pressure (increase in systolic with concurrent decrease in diastolic blood pressure) is an indication of increased ICP. Decerebrate posturingis correct. Both decerebrate and decorticate posturing indicate increased ICP [Show More]

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