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A nurse is caring for a client in an induced coma for increased intracranial pressure (ICP). What should the nurse assess next to determine this client's cerebral function?

A.

Glasgow Coma Scale

B.

Pupillary size and reaction

C.

Blood pressure and heart rate

D.

Gag Reflex

Answer and Explanation

The Correct Answer is B

A. The Glasgow Coma Scale is useful for assessing consciousness levels but may not be as sensitive for changes in brainstem function in a patient already in an induced coma.  

 

B. Assessing pupillary size and reaction provides critical information on brainstem function and can indicate changes in ICP. Changes in pupil size and reaction can signify worsening cerebral function or brain herniation.   

 

C. Blood pressure and heart rate are vital signs that can suggest increased ICP, but they are not as direct an indicator of cerebral function as pupil assessment.  

 

D. The gag reflex is important but does not provide as direct information about cerebral function related to ICP as pupillary assessment does.


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View Related questions

Correct Answer is D

Explanation

A. Exophthalmos is typically associated with hyperthyroidism (specifically Graves' disease) rather than hypothyroidism.

B. Diaphoresis (excessive sweating) is also more common in hyperthyroid states, not hypothyroidism.

C. Palpitations are indicative of an increased metabolic rate, which is common in hyperthyroidism; therefore, they would not be expected in a client with hypothyroidism.

D. Lethargy is a classic symptom of hypothyroidism due to decreased metabolism, leading to fatigue and reduced energy levels, making it the expected finding.

Correct Answer is B

Explanation

A. Hormone replacement is generally used to supplement deficiencies rather than inhibit excess hormone release.

B. Dopamine agonists, such as bromocriptine, are used to inhibit the release of growth hormone from the anterior pituitary, which is beneficial in treating acromegaly, a condition caused by excess growth hormone.

C. Levothyroxine is a thyroid hormone replacement and is not effective in controlling pituitary hormone release.

D. Corticosteroids do not inhibit growth hormone release and are typically used to manage inflammation rather than for pituitary hormone control.

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