A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?

Pin-point pupils

Irritability

Pallor

Decreased blood pressure

Answer and Explanation

The Correct Answer is B

A. Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light

B. Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.

C. Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.

D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.

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Free Nursing Study Resources

Correct Answer is A

Explanation

This statement demonstrates an understanding that music therapy can help divert the client's attention from the pain they are experiencing, providing a distraction and potentially reducing their awareness of the pain. Music therapy is often used as a complementary approach to pain management in hospice care, aiming to improve the client's comfort and well-being.

A. "Advance directives include instructions for resolving financial matters after my death." B. "Federal legislation dictates the legal guidelines for advance directives." C. "Advance directives include a living will." D. "My medical record should not include my advance directives."

Correct Answer is C

No explanation

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A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

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