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. Antibiotics are not typically used unless there is a specific infection; Meniere's is not caused by an infection.

B. Beta blockers are used for various cardiovascular conditions and may help with some vestibular disorders, but they are not the first-line treatment for Meniere's Disease.

C. Diuretics are commonly prescribed for Meniere's Disease to help reduce fluid retention and decrease endolymphatic pressure in the inner ear, which can help alleviate symptoms such as vertigo and hearing loss.

D. Antidepressants are not a primary treatment for Meniere's Disease, although they might be prescribed for anxiety or depression that may accompany the chronic nature of the disease.

A. Fifth intercostal space, left midclavicular line B. Fourth intercostal space, right sternal boarder C. Third intercostal space, left midclavicular line D. Second intercostal space, right sternal boarder

Correct Answer is A

Explanation

A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.

B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.

C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.

D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.

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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

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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)?