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?
Glasgow Coma Scale
Pupillary size and reaction
Blood pressure and heart rate
Gag Reflex
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 D
Explanation
A. Keeping the room brightly lit can be overstimulating and may increase ICP; therefore, a calm, dimly lit environment is preferable.
B. Encouraging coughing and deep breathing exercises could increase ICP and should be avoided unless specifically indicated.
C. Placing the client in a supine position is not recommended for clients with increased ICP; they should typically be positioned with the head elevated to promote venous drainage.
D. Implementing seizure precautions is critical as head injuries can lead to seizures, and ensuring the client's safety is a priority.
Correct Answer is B
Explanation
A. Weight gain is not typical in Addison's disease; instead, weight loss is common.
B. Hyperpigmentation, particularly in sun-exposed areas and skin folds, is a classic symptom of Addison's disease due to elevated ACTH levels.
C. Low blood pressure, not elevated, is common due to decreased cortisol levels.
D. Purple striations are more commonly seen in Cushing's syndrome rather than Addison's disease.