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)?

T98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air.

T92.5 F (33.6 C), BP 90/64, HR 80, RR 14, O2 Sat 97% Room Air.

T103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air.

T98.6 F (37 C), BP 200/94, HR 90, RR 18, O2 Sat 100% Room Air.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Extremely high systolic BP (220 mmHg), bradycardia (HR 30), and altered respirations (RR 6) suggest Cushing's triad, a hallmark of increased ICP due to severe brain injury.

Choice B rationale

Hypothermia (T92.5°F) and hypotension (BP 90/64) do not indicate increased ICP but may result from shock or hypothermic conditions affecting autonomic responses.

Choice C rationale

Hyperthermia (T103.1°F) and tachycardia (HR 132) are commonly seen in infection or hypermetabolic states, not directly pointing to raised ICP.

Choice D rationale

Mild hypertension (BP 200/94) with normal HR (90) and RR (18) does not fit the classic signs of increased ICP like Cushing's triad.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Proper nutrition, exercise, and stress reduction enhance psychological well-being, stimulating endorphin release, which improves mood and resilience, essential for managing chronic conditions like HIV.

Choice B rationale

These factors bolster immune function by reducing cortisol levels that impair immunity, supporting T-cell activity and promoting resistance against opportunistic infections common in HIV patients.

Choice C rationale

Maintaining strength and independence aids patients in daily functioning, reducing dependency and enhancing self-efficacy, which is critical for long-term adherence to therapeutic regimens in HIV.

Choice D rationale

Preventing virus transmission requires safe practices, not lifestyle changes alone. Nutrition and exercise cannot alter transmission mechanisms like exposure to body fluids.

Choice E rationale

Eliminating HIV completely necessitates antiretroviral therapy and advancements in medical science; lifestyle modifications alone are insufficient against viral integration within host DNA.

A. Bipolar disorder. B. Pre-existing liver disease. C. Asthma. D. Migraine headaches.

Correct Answer is B

Explanation

Choice A rationale

Bipolar disorder is an approved indication for valproic acid use. It helps stabilize mood swings, particularly mania, making it a suitable treatment rather than a contraindication.

Choice B rationale

Pre-existing liver disease contraindicates valproic acid because it increases the risk of hepatic toxicity and liver failure. Liver function must be closely monitored in all patients receiving this drug.

Choice C rationale

Asthma is not affected by valproic acid use as the drug targets neurological pathways and does not impact respiratory or bronchial systems significantly.

Choice D rationale

Valproic acid is used to treat migraines and seizures. It prevents the occurrence of severe headaches through stabilization of neuronal activity, making this an appropriate rather than contraindicated use. .

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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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Naxlex Comprehensive Predictor Exams

The nurse should educate clients who are HIV+ on proper nutrition, exercise, and stress reduction because these factors will: (Select All that Apply.)

Correct Answer is ["A","B","C"]

Explanation

The nurse knows that an important contraindication for valproic acid use is:

Correct Answer is B

Explanation

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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)?