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 B
Explanation
A. Serum thyroxine (T4) is typically decreased in primary hypothyroidism due to reduced thyroid hormone production.
B. In primary hypothyroidism, the thyroid gland fails to produce sufficient hormones, which leads to an increase in thyroid-stimulating hormone (TSH) as the pituitary gland tries to stimulate thyroid function. Elevated TSH is a common finding in primary hypothyroidism.
C. Serum T3 is usually decreased in primary hypothyroidism since the production of T3 and T4 is reduced.
D. Free T4 is typically low in primary hypothyroidism as the thyroid gland is underactive and not producing adequate levels of thyroid hormones.
Correct Answer is A
Explanation
A. In SIADH, excess ADH causes water retention and hyponatremia; fluid restriction helps to prevent further dilution of sodium and manage fluid balance.
B. NPO status is unnecessary unless otherwise indicated; managing fluid intake is more effective.
C. Increasing oral intake would worsen fluid overload and hyponatremia.
D. Rapid IV fluid infusion can exacerbate the client’s condition by increasing fluid volume further.