Increased Intracranial Pressure — Quiz

The nurse is planning care for a 68-year-old female client (Mrs. Alvarez) in the medical-surgical unit with increased intracranial pressure. Which tasks are appropriate to delegate to unlicensed assistive personnel (UAP)?

Select all that apply.

• AMeasuring and recording vital signs on a stable client
• BAssisting with ambulation and activities of daily living
• CPerforming the initial head-to-toe assessment
• DRecording intake and output
• ETeaching the client about a new medication
• FReporting an observed change in condition to the nurse

For a 68-year-old female client (Mrs. Alvarez) in the medical-surgical unit being treated for increased intracranial pressure, which findings should the nurse report to the provider immediately?

Select all that apply.

• ANew confusion or decreased level of consciousness
• BSystolic blood pressure below 90 mm Hg with symptoms
• COxygen saturation falling below the ordered target despite therapy
• DUrine output below 30 mL/hour for 2 consecutive hours
• EMild itching at an old, healed IV site
• FPain controlled at 2/10 after scheduled analgesia

The nurse reviews new laboratory results for a 68-year-old female client (Mrs. Alvarez) in the medical-surgical unit with increased intracranial pressure. Which result is most important for the nurse to act on first?

• AA critical value that changes the client's immediate risk (e.g., critical potassium, hemoglobin, or glucose)
• BA value slightly outside range but unchanged from the last three draws
• CA value trending slowly toward the reference range
• DA value within the expected reference range

Before administering a newly ordered high-alert medication to a 68-year-old female client (Mrs. Alvarez) in the medical-surgical unit with increased intracranial pressure, which action is the nurse's priority?

• AVerify allergies, the indication, baseline vitals/labs, and the specific adverse effect to monitor
• BAdminister the medication promptly, then document afterward
• CAsk the UAP to double-check the dose
• DWithhold the medication until the family arrives

The nurse is discharging a 68-year-old female client (Mrs. Alvarez) in the medical-surgical unit after treatment for increased intracranial pressure. Which statements by the client indicate correct understanding?

Select all that apply.

• A"I know the exact warning signs that mean I should call 911."
• B"I can name each of my medicines, what it is for, and when to take it."
• C"I will stop my medications once I feel better."
• D"I know which follow-up appointment I have and why."
• E"I should weigh myself and report sudden changes, if that applies to me."