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 D

Explanation

A. Using a draw sheet may cause twisting, which can compromise spinal alignment.

B. Asking the patient to assist may risk further spinal injury.

C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.

D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.

A. Sharing eating utensils B. Sharing a razor C. Kissing on the mouth D. Using the same toilet

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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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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