The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?
Altered mental status
Tachycardia and hypotension
Fixed and dilated pupils
Widening pulse pressure
The Correct Answer is A
A. Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.
B. Tachycardia and hypotension are not primary indicators of elevated ICP.
C. Fixed and dilated pupils indicate severe and often irreversible ICP increase, occurring later in the progression.
D. Widening pulse pressure is a later sign of increased ICP, following changes in mental status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Kaposi's Sarcoma is a cancer commonly associated with AIDS, characterized by purple or brown lesions on the skin and mucous membranes. It is linked to human herpesvirus-8 (HHV-8) and is often seen in immunocompromised individuals.
B. Candidiasis stomatitis involves oral or esophageal thrush, presenting as white patches rather than purple or brown lesions.
C. Cryptosporidiosis is a parasitic infection causing severe diarrhea but does not manifest as skin lesions.
D. Meningitis can cause neurological symptoms and systemic infection but does not present with purple or brown skin spots.
Correct Answer is B
Explanation
A. Sharing eating utensils does not transmit HIV, as the virus is not spread through saliva.
B. Sharing razors is a high-risk activity for transmitting HIV because it can involve direct blood-to-blood contact if the razor causes cuts.
C. HIV transmission through kissing is highly unlikely due to low levels of the virus in saliva.
D. HIV cannot be spread through shared toilets, as the virus does not survive on surfaces and is not spread through casual contact.
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