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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Reorienting confused patients is important but is not directly related to cerebellar injury.

B. While turning every 2 hours is important to prevent pressure injuries, it does not address the specific fall risk associated with cerebellar damage.

C. The cerebellum is responsible for balance and coordination, so injuries in this area increase the risk of falls. Ensuring the bed alarm is on provides immediate alerts if the patient attempts to get out of bed, helping to prevent falls.

D. Varying the schedule to prevent boredom is not a priority in the care of patients with cerebellar injury.

A. Take this medication with food or milk B. Get potassium levels drawn periodically C. Increase intake of green vegetables D. Use salt substitute for cooking

Correct Answer is B

Explanation

A. While taking some medications with food or milk can help with absorption, this is not a specific requirement for lisinopril.

B. Lisinopril, an ACE inhibitor, can lead to elevated potassium levels. Periodic monitoring of potassium levels is essential to prevent hyperkalemia, a potentially dangerous side effect.

C. Increasing intake of green vegetables is generally healthy but does not directly impact lisinopril's effects.

D. Many salt substitutes contain potassium, which could elevate potassium levels further when taken with ACE inhibitors like lisinopril, posing a risk for hyperkalemia.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with a brain injury to the cerebellum. Which nursing intervention is priority?

Correct Answer is C

Explanation

The nurse is caring for a patient who will be discharged with a prescription for lisinopril. What discharge teaching should be provided related to this medication?

Correct Answer is B

Explanation

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