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 D

Explanation

A. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer?" This statement reflects anger rather than denial. In the anger stage of grief, individuals may direct their frustration toward others, including healthcare providers, feeling that they have been wronged or mistreated.

B. "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed." This statement indicates depression rather than denial. Depression in the grieving process often includes feelings of fatigue, sadness, or a lack of motivation, and is characterized by a sense of hopelessness or resignation.

C. "The doctor has been so good to me. I know he has tried everything he can. It is just my time." This statement indicates acceptance, the final stage of the grief process. Acceptance involves coming to terms with the reality of the situation, recognizing that the end is near, and being at peace with it.

D. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." Denial is a defense mechanism in which the person refuses to accept the reality of the situation. In this case, the client is rejecting the doctor's prognosis, believing that the doctor is exaggerating, which is characteristic of the denial phase of grief.

A. “I understand your fears. I was a smoker also.” B. "Don't worry. The important thing is you have now quit smoking." C. “It's okay to feel scared. Let's talk about what you are afraid of." D. “Your doctor is a great surgeon. You will be fine."

Correct Answer is C

Explanation

A. “I understand your fears. I was a smoker also.” This response shifts focus to the nurse's experience, which is not therapeutic or client-centered.
B. "Don't worry. The important thing is you have now quit smoking." This response dismisses the client’s emotional expression and minimizes her fear.
C. “It's okay to feel scared. Let's talk about what you are afraid of." This is the most therapeutic response. It validates the client’s feelings and encourages open communication.
D. “Your doctor is a great surgeon. You will be fine." This response is reassuring but dismissive, and it doesn't address the client’s expressed emotions.

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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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