Page 2056 - Saunders Comprehensive Review For NCLEX-RN

Rationale: Activities that increase intrathoracic and intraabdominal pressures
cause an indirect elevation of the intracranial pressure. Some of these activities
include isometric exercises, Valsalva’s maneuver, coughing, sneezing, and blowing
the nose. Exhaling during activities such as repositioning or pulling up in bed opens
the glottis, which prevents intrathoracic pressure from rising.
Test-Taking Strategy: Focus on the subject, preventing elevations in intracranial
pressure. Evaluate each option in terms of the tension it puts on the body. Doing so
will help you eliminate each incorrect option systematically.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Head injury/trauma
Priority Concepts: Client Education; Intracranial Regulation
Reference: Ignatavicius, Workman, Rebar (2018), pp. 936-937.

707. Answer: 4

Rationale: Leakage of cerebrospinal fluid (CSF) from the ears or nose may
accompany basilar skull fracture. CSF can be distinguished from other body fluids,
because the drainage will separate into bloody and yellow concentric rings on
dressing material, called a halo sign. The fluid also tests positive for glucose.
Test-Taking Strategy: Focus on the subject, the characteristics of CSF. Recall that
CSF contains glucose, whereas other secretions, such as mucus, do not. Knowing
that CSF separates into rings also will help you answer this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Neurological
Health Problem: Adult Health: Neurological: Head injury/trauma
Priority Concepts: Clinical Judgment; Intracranial Regulation
Reference: Ignatavicius, Workman, Rebar (2018), p. 946.

708. Answer: 1, 2, 4

Rationale: The most frequent cause of autonomic dysreflexia is a distended
bladder. Straight catheterization should be done every 4 to 6 hours (catheterization
every 12 hours is too infrequent), and urinary catheters should be checked
frequently to prevent kinks in the tubing. Constipation and fecal impaction are other
causes, so maintaining bowel regularity is important. Ensuring a bowel movement
once a week is much too infrequent. Other causes include stimulation of the skin
from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk
in these areas.
Test-Taking Strategy: Focus on the subject, preventing autonomic dysreflexia.
Remember that autonomic dysreflexia is caused by noxious stimuli to the bowel,
bladder, or skin. With this in mind, you can eliminate easily each of the incorrect
options.

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