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)?

Restlessness and altered mental status.

Widening pulse pressure.

Fixed and dilated pupils.

Tachycardia and hypotension.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Restlessness and altered mental status are early signs of increasing intracranial pressure, resulting from cerebral edema compressing neural tissue and reducing oxygen supply to critical brain regions.

Choice B rationale

Widening pulse pressure is a later sign of increased intracranial pressure, indicating significant disruption of autonomic regulation and brainstem function. Early symptoms like restlessness occur first.

Choice C rationale

Fixed and dilated pupils signify severe and advanced intracranial pressure, often indicating brain herniation, which is a critical stage beyond initial compensatory mechanisms.

Choice D rationale

Tachycardia and hypotension are not hallmark signs of raised intracranial pressure. Bradycardia and hypertension align more closely with Cushing's triad, associated with late-stage intracranial hypertension. .

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale

Hypertension is not the primary concern in cervical spinal cord injuries at C-3, where respiratory compromise due to diaphragm paralysis is the leading cause of complications or mortality.

Choice B rationale

Bradycardia can occur due to vagal stimulation in spinal injuries but is less life-threatening compared to the respiratory compromise caused by diaphragmatic paralysis.

Choice C rationale

Sepsis may develop in spinal cord injury patients, particularly from infections like pneumonia or urinary tract infections, but respiratory failure is the most acute concern at C-3.

Choice D rationale

Respiratory compromise occurs due to impaired diaphragm function at C-3, making it the primary cause of morbidity or mortality, necessitating prompt respiratory support and monitoring.

A. Ask the patient why they are behaving in this manner. B. Recommend an order for 1:1 observation status. C. Point out and identify the behavior as unacceptable. D. Have the patient return to his room when this occurs.

Correct Answer is C

Explanation

Choice A rationale

Asking the patient why they are behaving inappropriately does not address or stop the behavior. This approach may escalate the situation, leading to further discomfort for others.

Choice B rationale

Recommending 1: observation without addressing the behavior does not teach social boundaries. It is a passive solution that misses the opportunity for behavior correction.

Choice C rationale

Pointing out the behavior as unacceptable sets clear boundaries and educates the patient on appropriate social conduct. It creates an opportunity for the patient to reflect and adjust their behavior.

Choice D rationale

Having the patient return to their room may temporarily stop the behavior but does not educate the patient or reinforce appropriate boundaries for public settings.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 in the acute care setting with a spinal cord injury at the level of C-3. The nurse understands that the main cause of complications or death related to this injury includes:

Correct Answer is D

Explanation

The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior.What would be the best response by the nurse?

Correct Answer is C

Explanation

The nurse knows that an important contraindication for valproic acid use is:

A nurse is caring for a client who has had repeated instances of cystitis.When considering possible ascending progression of the infection, the client should be taught to monitor for:

A client is to receive 250 mL of IV fluid over 90 minutes by gravity. The drop factor on the IV tubing is 20 gtts/mL. How many gtts/min should be administered?

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate an order for which of the following medications to manage increases in intracranial pressure (ICP)?

A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?

The nurse is caring for several patients in the Intensive Care Unit (ICU). Which of the following patients is at the greatest risk of anoxic brain injury?

The nurse recognizes that teaching a client to wash the hands after using the bathroom is an attempt to break the chain of infection between the:

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)?