A nurse closely monitors a patient with a head injury. Upon assessment of vital signs, the nurse notes changes indicative of increased intracranial pressure caused by brain swelling. Which changes depict increased intracranial pressure?
1. Decreased temperature and decreased blood pressure
2. Increased blood pressure, increased temperature, increased respirations, and increased pulse rate
3. Decreased blood pressure, increased pulse rate, and increased respiratory rate
4. Increased blood pressure, decreased respiratory rate, and decreased pulse rate
Question 2
A nurse, unable to palpate the left pedal pulse on a patient with diabetes, should next
1. Chart: Unable to palpate left pedal pulse.
2. Notify the physician that the pulse could not be palpated.
3. Use the Doppler to listen for the left pedal pulse.
4. Call the nurse supervisor to report the pedal pulse was zero.
Nurses possess a wide variety of experiences which they take into each patient encounter.
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