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. This is a correct statement, as using multiple drugs helps to reduce the likelihood of resistance and enhances viral suppression.

B. This is accurate; if resistance develops, alternative medications or combinations can be considered.

C. This statement indicates a misunderstanding. Antiretroviral medications do not kill the virus; they suppress its replication. Lifelong adherence to antiretroviral therapy is necessary to manage HIV and prevent viral rebound.

D. Correct, as an effective regimen should lead to an increase in CD4 count and improved immune function.

A. "I should discuss all over the counter drugs with my healthcare provider." B. "I cannot discontinue medication abruptly." C. "If I miss a dose, I can double up on the next dose." D. "I should take my medications exactly as ordered."

Correct Answer is C

Explanation

A. Discussing over-the-counter drugs with the healthcare provider is essential, as they can interact with antiepileptic medications.

B. Discontinuing antiepileptic medications abruptly can lead to rebound seizures and is unsafe, so this statement is correct.

C. Doubling up on doses can lead to toxicity and adverse effects; missed doses should not be made up by doubling the next dose. This response indicates the need for further teaching.

D. Taking medications exactly as prescribed is necessary to maintain therapeutic levels and manage seizure control effectively.

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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)?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is C

Explanation

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