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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
Choice A rationale
Brown-Sequard injury results in ipsilateral motor function loss due to corticospinal tract damage and contralateral pain/temperature loss from spinothalamic tract disruption, characteristic of this hemisection spinal cord injury.
Choice B rationale
Central cord injury affects cervical spine and hand function but does not exhibit hemisection symptoms like ipsilateral motor loss or contralateral sensory loss. Symptoms vary and commonly include upper limb weakness.
Choice C rationale
Posterior cord injury primarily impacts dorsal column function, resulting in loss of proprioception and vibration sense. Motor and pain/temperature functions are preserved, unlike in Brown-Sequard injury.
Choice D rationale
Anterior cord injury involves ischemic damage to the anterior spinal artery, leading to motor paralysis and pain/temperature loss bilaterally, not ipsilateral and contralateral as described in the question.
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