A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?

Correct Answer: B

Rationale: The correct answer is B: Intracranial pressure (ICP) of 20 mm Hg. Elevated ICP can lead to increased intracranial pressure, which can further damage brain tissue and impair cerebral perfusion. This is a critical finding that requires immediate intervention to prevent further brain damage. A: Urine output of 100 mL/hour is within the normal range and does not pose an immediate threat to the client's condition. C: Respiratory rate of 12 breaths/minute is within normal limits and does not indicate an immediate concern. D: Mean arterial pressure (MAP) of 70 mm Hg is within the normal range for most adults and does not require immediate intervention in this scenario.

Correct Answer: C

Rationale: The correct answer is C: Place the client in Trendelenburg position. This is the first action to take in a client with suspected air embolism, a potential complication of central line insertion. Placing the client in Trendelenburg position with the head down and the legs elevated can help prevent air from reaching the heart and lungs. This action can help stabilize the client's condition before further interventions can be implemented. Stopping the TPN infusion (choice A) can be important, but the priority in this situation is to address the potential air embolism. Notifying the healthcare provider (choice B) can be done after the immediate intervention. Administering oxygen (choice D) is important, but placing the client in Trendelenburg position takes precedence in this emergency situation.

Correct Answer: A

Rationale: The correct answer is A: Tardive dyskinesia. Haloperidol is a first-generation antipsychotic known to cause extrapyramidal side effects, including tardive dyskinesia, which is characterized by involuntary repetitive movements of the face and body. This side effect is a serious concern due to its potential to be irreversible. Monitoring for tardive dyskinesia is crucial in clients taking haloperidol to detect and manage symptoms promptly. Explanation for incorrect choices: B: Orthostatic hypotension - This side effect is more commonly associated with other antipsychotic medications, particularly second-generation ones. C: Photosensitivity - Haloperidol does not typically cause photosensitivity as a side effect. D: Hyperglycemia - While some antipsychotic medications may lead to metabolic side effects like hyperglycemia, haloperidol is not typically associated with this specific side effect.

Correct Answer: A

Rationale: The correct answer is A: Rebound tenderness at McBurney's point. McBurney's point is located in the right lower quadrant and is a classic sign of appendicitis. Rebound tenderness at this point indicates inflammation in the peritoneum, suggesting appendicitis. Choices B, C, and D are not specific to appendicitis. Positive Murphy's sign is related to cholecystitis, Rovsing's sign is seen in acute appendicitis but is not as specific as rebound tenderness at McBurney's point, and Cullen's sign is associated with acute pancreatitis.

Correct Answer: B

Rationale: The correct answer is B because eating a snack when blood glucose is 70 mg/dl helps prevent hypoglycemia. Testing blood glucose once a week (A) is not frequent enough for proper management. Taking extra insulin when shaky (C) can lead to hypoglycemia. Skipping meals (D) can cause unstable blood glucose levels.