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. .

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Correct Answer is B

Explanation

Choice A rationale

Fluid intake does not directly impact intraocular pressure. Management of glaucoma focuses on medications like eye drops and surgical interventions rather than restricting fluid intake.

Choice B rationale

Glaucoma treatments, including eye drops, aim to manage intraocular pressure. These medications are required lifelong to prevent optic nerve damage and preserve vision.

Choice C rationale

Excess salt impacts systemic blood pressure but does not directly influence intraocular pressure. Glaucoma management targets ocular pressure, not dietary sodium reduction.

Choice D rationale

Avoiding eye overuse may reduce strain but does not address intraocular pressure. Effective glaucoma treatment relies on pharmacological or surgical measures rather than activity limitation.

A. By threading it through the femoral artery to the brain. B. To monitor intracranial pressure (ICP) and drain cerebral spinal fluid. C. After the patient has an electroencephalogram (EEG). D. Due to having minimal risk for infection.

Correct Answer is B

Explanation

Choice A rationale

Ventriculostomies are inserted directly through the skull into the ventricles, not via the femoral artery. This method provides direct access to cerebrospinal fluid for drainage and pressure monitoring.

Choice B rationale

Ventriculostomies are placed to monitor intracranial pressure and drain excess cerebrospinal fluid, managing conditions like hydrocephalus or elevated intracranial pressure following brain injury or surgery.

Choice C rationale

An EEG monitors electrical brain activity but is unrelated to ventriculostomy placement. Ventriculostomy focuses on fluid drainage and pressure management, not on electrical diagnostic procedures.

Choice D rationale

Ventriculostomies carry a significant risk of infection due to the invasive nature of the procedure. Proper aseptic technique is critical to minimizing, not eliminating, the risk of infection.

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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)?