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. Nitroprusside is a vasodilator and is not used for managing ICP; it can increase intracranial pressure if not carefully monitored.

B. Furosemide is a diuretic but is less effective for ICP reduction compared to hypertonic saline or mannitol.

C. Hypertonic saline (3% Normal Saline) is used to reduce intracranial pressure by drawing fluid out of the brain tissue and into the bloodstream, which can help prevent cerebral edema.

D. Norepinephrine is a vasopressor and is not used specifically to manage intracranial pressure.

A. 28 units B. 42 units C. 14 units D. 32 units

Correct Answer is B

Explanation

A. 28 units only accounts for the NPH insulin dosage and does not include the regular insulin dosage.

B. Adding 14 units of regular insulin and 28 units of NPH insulin results in a total of 42 units, the correct dose to prepare in the syringe.

C. 14 units only accounts for the regular insulin dosage and does not include the NPH insulin dosage.

D. 32 units is not the correct total dose; it underestimates the combined dosage.

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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

Explanation

Correct Answer is B

Explanation

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