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. While monitoring for dysrhythmias is important for certain cardiovascular conditions, it is not the primary concern for an AAA. The management of blood pressure and preventing rupture are higher priorities.

B. While blood clots can be a concern in some cardiovascular conditions, thrombus formation is not a primary concern with AAA management unless other risk factors (such as venous stasis or atrial fibrillation) are present.

C. Monitoring for bleeding would be more relevant if the aneurysm were large or there were signs of rupture, but for a small AAA, the primary concern is managing blood pressure and preventing further enlargement. Bleeding monitoring is more critical in cases of rupture or larger aneurysms.

D. Antihypertensive medications are crucial for controlling blood pressure and preventing further stress on the aneurysm. Adherence to these medications is essential in managing the condition medically to reduce the risk of rupture or further enlargement of the aneurysm.

A. "My oncologist will continue to look for a cure for my cancer while I am receiving hospice care." B. Hospice care services are available to patients who are terminally ill regardless of their life expectancy C. I will have to be admitted to a long term care facility in order to receive hospice care D. I should expect the hospice team to help me manage my son

Correct Answer is D

Explanation

A. Hospice care is intended for clients who are no longer pursuing curative treatment. The focus shifts from curing the disease to providing comfort, pain management, and emotional support at the end of life.

B. Hospice care is specifically for individuals who have a prognosis of 6 months or less to live, assuming the illness runs its normal course. This eligibility criterion is central to receiving hospice services.

C. Hospice care can be provided in various settings, including the client’s home, a hospice facility, a hospital, or a long-term care facility. Admission to a specific facility is not a requirement.

D. Hospice care focuses on symptom management, pain control, and quality of life for clients who are terminally ill. The interdisciplinary hospice team addresses the physical, emotional, spiritual, and social needs of the client.

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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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