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 ["D","E"]
Explanation
Choice A rationale
Weekly appointments to change the catheter are unnecessary unless specifically indicated. Most urinary catheters are changed monthly or as needed based on physician's discretion or complications.
Choice B rationale
Sexual intimacy is possible with an indwelling urinary catheter if handled properly. Providing education on safe practices promotes normalcy and quality of life for the patient.
Choice C rationale
Wearing underwear is recommended to protect the catheter and minimize risk of contamination or accidental dislodgement. This information supports proper hygiene and comfort.
Choice D rationale
Regular emptying of the leg bag every 4 hours or more frequently prevents overfilling, which could lead to backflow and increased risk of urinary tract infections.
Choice E rationale
Foul-smelling, cloudy urine can indicate infection such as a urinary tract infection. Prompt reporting ensures early treatment and prevention of complications.
Correct Answer is B
Explanation
Choice A rationale
Administering oxygen at 6 liters per minute via nasal cannula risks hypercapnia in a client with emphysema due to impaired CO2 elimination. Oxygen should be titrated to maintain safe saturation levels, usually 88–92%.
Choice B rationale
Ipratropium is a bronchodilator that safely alleviates airway constriction in emphysema without systemic cardiovascular effects, making it suitable for a client with coronary artery disease and chronic obstructive pulmonary conditions.
Choice C rationale
Propranolol is contraindicated in emphysema due to its beta-blocking effects, which may exacerbate bronchoconstriction and reduce respiratory function, posing a significant risk to the client’s health.
Choice D rationale
Organic herbal supplements lack evidence-based safety and efficacy, especially in complex medical conditions like coronary artery disease and emphysema. They can also interact adversely with prescribed medications.
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