1. A nurse is caring for a client who has a closed head injury and has an intraventricular

catheter placed. Which of the following findings indicates that the client is experiencing

increased ICP?

a. Flat jugular veins

b. GCS score of 15

c. Sleepiness exhibited by the client

d. Widening pulse pressure

e. Decerebrate posturing

f. Flat jugular veins is incorrect. With increased ICP, the jugular veins are typically

distended.

A Glasgow Coma Scale score of 15 is incorrect. A Glasgow Coma Scale score of

15 indicates neurological functioning within the expected reference range for eye

opening, motor, and verbal response.

Sleepiness exhibited by the client is correct. Sleepiness or difficulty arousing the

client from sleep is an indication of increased ICP.

Widening pulse pressure is correct. A widening pulse pressure (increase in

systolic with concurrent decrease in diastolic blood pressure) is an indication of

increased ICP.

Decerebrate posturing is correct. Both decerebrate and decorticate posturing

indicate increased ICP.

2. A nurse is preparing a client who has supraventricular tachycardia for elective

cardioversion. Which of the following prescribed medications should the nurse instruct the

clients to withhold for 48hr prior to cardioversion?

a. Enoxaparin

b. Metformin

c. Diazepam

d. Digoxin

e. Anticoagulants can be beneficial during cardioversion due to their ability to prevent

blood clots that can be released into the client's circulatory system after

cardioversion. This medication should not be withheld.

f. Metformin

g. Metformin might be withheld for a client scheduled for cardiac catheterization or

other procedures involving contrast dye in order to prevent damage to the kidneys.

However, metformin should not be withheld prior to cardioversion.