A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure (ICP)?
Hypertension
Tinnitus
Hypotension
Tachycardia
The Correct Answer is A
Choice A reason:
Hypertension is a common manifestation of increased intracranial pressure (ICP). As ICP rises, the body attempts to maintain cerebral perfusion by increasing blood pressure. This compensatory mechanism helps ensure that the brain continues to receive adequate blood flow despite the elevated pressure.
Choice B reason:
Tinnitus, or ringing in the ears, is not a typical manifestation of increased ICP. While it can be a symptom of various conditions, it is not specifically associated with elevated intracranial pressure.
Choice C reason:
Hypotension, or low blood pressure, is not a manifestation of increased ICP. In fact, the body typically responds to increased ICP with hypertension to maintain cerebral perfusion. Hypotension would be concerning for other reasons but is not indicative of elevated intracranial pressure.
Choice D reason:
Tachycardia, or an increased heart rate, is not a primary manifestation of increased ICP. While changes in heart rate can occur with severe neurological conditions, hypertension is a more direct indicator of elevated intracranial pressure.
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Correct Answer is ["A","B","C"]
Explanation
Choice A reason:
Conflict resolution skills are essential for effective nurse leadership. Leaders must be able to manage and resolve conflicts within the team to maintain a positive and productive work environment. Effective conflict resolution promotes teamwork and improves patient care.
Choice B reason:
Integrity is a fundamental quality of an effective nurse leader. Leaders with integrity are honest, ethical, and trustworthy. They set a positive example for their team and build a culture of trust and respect.
Choice C reason:
The ability to set priorities is crucial for nurse leaders. Effective leaders can identify the most important tasks and allocate resources appropriately. This skill ensures that the team focuses on activities that have the greatest impact on patient care and outcomes.
Choice D reason:
An authoritarian leadership style is not characteristic of effective nurse leadership. This style can lead to a lack of collaboration and low team morale. Effective nurse leaders typically use a more collaborative and inclusive approach to leadership.
Choice E reason:
Being resistant to change is not a quality of an effective nurse leader. Healthcare is a dynamic field that requires adaptability and openness to new ideas and practices. Effective leaders embrace change and guide their teams through transitions to improve care and outcomes.
Correct Answer is A
Explanation
Choice A: Red tag
A red tag is assigned to patients who require immediate medical attention and intervention to survive. These patients have life-threatening injuries but have a high chance of survival if treated promptly. In this scenario, the client has a respiratory rate of 38, a weak and rapid pulse, and uncontrolled bleeding. These symptoms indicate severe physiological distress and potential shock, necessitating immediate intervention to prevent death. According to NATO triage guidelines, such critical conditions warrant a red tag to prioritize urgent care1.
Choice B: Black tag
A black tag is used for patients who are deceased or have injuries so severe that survival is unlikely even with immediate medical intervention. This category is also known as “expectant” and is used to allocate resources to those with a higher chance of survival. The client in this scenario, despite having severe symptoms, is not described as being beyond the possibility of survival, thus a black tag would not be appropriate1.
Choice C: Green tag
A green tag is assigned to patients with minor injuries who can wait for medical treatment without immediate risk to life. These patients are often referred to as “walking wounded.” The client’s symptoms of a high respiratory rate, weak and rapid pulse, and uncontrolled bleeding are far too severe to be classified under this category. Assigning a green tag would delay critical care, potentially leading to fatal outcomes1.
Choice D: Yellow tag
A yellow tag is for patients who have serious injuries but whose treatment can be delayed without immediate risk to life. These patients need medical attention but are stable enough to wait for a short period. Given the client’s symptoms, particularly the uncontrolled bleeding and signs of shock, delaying treatment could result in rapid deterioration. Therefore, a yellow tag would not be suitable in this case1.