A client required endotracheal intubation with sedation due to being in status epilepticus.
An electroencephalogram (EEG) monitor is prescribed by the physician.
The client's family member asks, "if he's resting now, why does he need that monitor too?" The nurse instructs the family member that the EEG:

Helps determine if there has been bleeding to brain tissue.

Checks for adequate oxygen intake by cerebral tissue.

Will assess brain waves to see if seizure activity is still occurring.

Answer and Explanation

The Correct Answer is C

Choice A rationale

While bleeding could indicate trauma, EEG does not detect blood presence or volume but instead evaluates electrical brain activity indicative of neuronal function.

Choice B rationale

Cerebral oxygen intake assessment requires pulse oximetry or arterial blood gas analysis rather than EEG, which monitors electrical signals, not oxygenation status.

Choice C rationale

EEG identifies abnormal brain wave patterns suggesting ongoing seizure activity, even in sedated patients, aiding in targeted interventions and preventing potential complications.

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Correct Answer is A

Explanation

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. .

A. T98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air. B. T92.5 F (33.6 C), BP 90/64, HR 80, RR 14, O2 Sat 97% Room Air. C. T103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air. D. T98.6 F (37 C), BP 200/94, HR 90, RR 18, O2 Sat 100% Room Air.

Correct Answer is A

Explanation

Choice A rationale

Extremely high systolic BP (220 mmHg), bradycardia (HR 30), and altered respirations (RR 6) suggest Cushing's triad, a hallmark of increased ICP due to severe brain injury.

Choice B rationale

Hypothermia (T92.5°F) and hypotension (BP 90/64) do not indicate increased ICP but may result from shock or hypothermic conditions affecting autonomic responses.

Choice C rationale

Hyperthermia (T103.1°F) and tachycardia (HR 132) are commonly seen in infection or hypermetabolic states, not directly pointing to raised ICP.

Choice D rationale

Mild hypertension (BP 200/94) with normal HR (90) and RR (18) does not fit the classic signs of increased ICP like Cushing's triad.

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Naxlex Comprehensive Predictor Exams

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)?

Correct Answer is A

Explanation

The nurse is caring for a patient with an acute brain injury.Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Correct Answer is A

Explanation

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