1. A nurse is caring for a client who has a closed head injury and has an intraventricular catheter placed. Which ofthe following findings indicates that the client is experiencing increased ICP? SATA. a. Flat jugular veins b. GCS score of 15 c. Sleepiness exhibited by the client d. Widening pulse pressure e. Decerebrate posturing f. Flat jugular veins are incorrect. With increased ICP, the jugular veins are typically distended.
A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of 15 indicates neurological functioning within the expected reference range for eye-opening, motor, and verbal response.
The sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the client fromsleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in systolic withaconcurrent decrease in diastolic blood pressure) is an indication of increased ICP.
Decerebrate posturing is correct. Both decerebrate and decorticate posturing indicate increased ICP. 2. A nurse is preparing a client who has supraventricular tachycardia for elective cardioversion. Which of thefollowing prescribed medications should the nurse instruct the clients to withhold for 48hr prior to cardioversion? a. Enoxaparin b. Metformin c. Diazepam d. Digoxin
e. Anticoagulants can be beneficial during cardioversion due to their ability to preventblood clots that can be released into the client's circulatory system after cardioversion. This medication should not be withheld. f. Metformin g. Metformin might be withheld for a client scheduled for cardiac catheterization or other procedures involving contrast dye to prevent damage to the kidneys. However, metformin should not be withheld prior to
cardioversion
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