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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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Correct Answer is C

Explanation

A. Feeling fatigued is not indicative of a therapeutic response; rather, patients should experience increased energy levels with appropriate therapy.

B. Decreased thyroxine levels are not the primary goal of levothyroxine therapy, which aims to normalize thyroid hormone levels in the body.

C. Decreased thyroid-stimulating hormone (TSH) levels indicate that the body is responding well to levothyroxine, as TSH production decreases when thyroid hormone levels are adequate.

D. Bradycardia and hypotension are not desired effects of levothyroxine and indicate potential under-treatment or other issues rather than a therapeutic response.

Correct Answer is B

Explanation

A. Weight gain is not a symptom of hyperthyroidism; in fact, patients often experience weight loss.

B. Beta blockers are commonly used to manage symptoms of tachycardia and palpitations associated with hyperthyroidism, as they help to decrease heart rate and reduce anxiety.

C. Weight loss is a typical symptom of hyperthyroidism, and beta blockers do not address this issue directly.

D. Depression is not a primary indication for beta blocker use in hyperthyroidism; instead, they are more focused on managing the cardiovascular symptoms associated with the condition.

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