autonomic dysreflexia/IICP

A nurse is planning care for a client following a stroke. Which of the following interventions should the nurse identify as the priority in the client's plan of care?

Monitor the client for increased intracranial pressure

A nurse is assessing an infant who is at risk for increased intracranial pressure. Which of the following findings should indicate to the nurse that this complication is developing?

High-pitched cry

A nurse is assessing a client who has increased intracranial pressure and has received IV mannitol. Which of the following findings indicates a therapeutic effect of this medication?

Increase urine output

A nurse is caring for a client who is experiencing autonomic dysreflexia due to a C5 spinal cord injury. After checking the client's vital signs, which of the following actions should the nurse perform next?

Place the client in a high-fowler's position

A nurse is assessing a client who has a high-thoracic spinal cord injury. The nurse should identify which of the following findings as a manifestation of autonomic dysreflexia?

Report of a headache

A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased intracranial pressure. This increase in ICP is due to which of the following?

Rigid skull containing cranial contents

A nurse is assessing a child who sustained a head injury. During the assessment, the nurse observes a clear drainage leaking from the child's nose. Which of the following actions should the nurse take?

Test the nasal secretions for glucose

A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of increased ICP. Which of the following findings indicates that the medication is having a therapeutic effect?

The client's serum osmolarity is 310 mOsm/L

A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure?

Widening pulse pressure

A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure?

dilated pupils