The nurse is caring for a client with an acute head injury. Which assessment finding would first alert the nurse that the client is developing an Increase in intracranial pressure?

Widening pulse pressure

Increasing restlessness

Decrease in the pulse rate

Dilated fixed pupils

Answer and Explanation

The Correct Answer is B

A. A widening pulse pressure (the difference between systolic and diastolic blood pressure) can be a sign of increasing intracranial pressure (ICP), but it typically occurs later in the progression of ICP. Early signs of increased ICP are often more subtle and include changes in behavior and consciousness.

B. One of the earliest signs of increased ICP is altered mental status or behavioral changes, such as increasing restlessness or agitation. As pressure builds inside the skull, it affects the brain's ability to function normally, leading to these early signs. Restlessness may indicate that the brain is becoming less able to maintain normal function due to the increasing pressure.

C. A decrease in pulse rate may occur later in the course of increased ICP, particularly with severe increases in pressure. However, early signs typically involve changes in consciousness and mental status rather than changes in vital signs like heart rate.

D. Dilated and fixed pupils are a late sign of increased ICP and usually indicate significant brain herniation or severe neurological compromise. While they are serious and require immediate attention, they do not typically occur at the early stages of increased ICP.

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Correct Answer is B

Explanation

A. Urticaria (hives) is not a common side effect of radiation therapy. The skin should be examined for localized radiation-induced skin changes, such as erythema or dryness, rather than generalized urticaria.
B. Radiation therapy can weaken the immune system, increasing the risk of infection. The nurse should monitor for signs of infection, especially in areas affected by radiation, as the skin and mucous membranes can become more vulnerable.
C. Low hemoglobin is not a direct or immediate concern related to radiation therapy for lung cancer. However, it could occur if the patient experiences bone marrow suppression, but this is not typically the primary concern for radiation therapy to the lung.
D. Xerostomia (dry mouth) is more commonly associated with radiation therapy to the head and neck area. Radiation to the lungs generally does not affect salivary glands, so monitoring for xerostomia is not necessary in this case.

A. "should check my skin monthly for any changes." B. I should avoid the use of tanning booths." C. I should use sunscreen even on cloudy days" D. Eating high a high fiber diet will reduce my risk for developing skin cancer

Correct Answer is D

Explanation

A. Checking the skin monthly for changes is a recommended practice for detecting early signs of skin cancer, such as new moles or changes to existing ones.
B. Avoiding the use of tanning booths is important because artificial tanning increases the risk of skin cancer, particularly melanoma.
C. Using sunscreen even on cloudy days is advised, as UV rays can penetrate clouds and still harm the skin.
D. A high-fiber diet, while beneficial for overall health, does not specifically reduce the risk of developing skin cancer. Risk reduction for skin cancer is more related to sun protection and avoiding UV radiation exposure.

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The nurse is caring for a client with an acute head injury. Which assessment finding would first alert the nurse that the client is developing an Increase in intracranial pressure?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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