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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. 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 is 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.
Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the
client from sleep is an indication of increased ICP.
Widening pulse pressure is correct. A widening pulse pressure (increase in
systolic with concurrent 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 the following 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 prevent
blood 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 in order to prevent damage to the kidneys.
However, metformin should not be withheld prior to cardioversion.
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