The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air

T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air

T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air

T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Answer and Explanation

The Correct Answer is B

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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Correct Answer is C

Explanation

A. The occipital lobe primarily processes visual information and is less involved in object identification errors.

B. The frontal lobe governs behavior, personality, and decision-making rather than object identification.

C. The parietal lobe is involved in processing sensory information and object recognition. Misidentifying objects can indicate damage to this area of the brain.

D. The temporal lobe is associated with auditory processing and memory, not typically object recognition errors.

A. not having sexual intercourse under the influence of drugs. B. asking those who they share equipment with to be tested for HIV. C. participating in a needle exchange program. D. cleaning syringe with betadine before use.

Correct Answer is C

Explanation

A. Avoiding sexual intercourse under the influence of drugs reduces certain risks but does not address the specific risk of needle transmission.

B. Asking others to be tested for HIV may be unrealistic and does not prevent HIV transmission through shared equipment.

C. Participating in a needle exchange program reduces the risk of HIV transmission by providing sterile needles, lowering the likelihood of infection from shared or contaminated needles.

D. Cleaning needles with betadine is not effective for HIV prevention; only sterile, unused needles should be used.

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The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

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Explanation

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Explanation

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