A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.
What is the priority action by the nurse?

Continue with assessment and document findings.

Suction the patient to minimize secretions.

Notify the physician and raise the head of the bed 35–45 degrees.

Lower the head of the bed and pad the side rails.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.

Choice B rationale

Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.

Choice C rationale

Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.

Choice D rationale

Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.

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Correct Answer is B

Explanation

Choice A rationale

The frontal lobe controls executive functions like reasoning and planning, not object identification errors. Damage here leads to issues with decision-making and voluntary movement, not misidentification of objects.

Choice B rationale

The temporal lobe processes auditory information and object recognition. Injury disrupts the brain's ability to associate visual stimuli with correct labels, causing errors like calling a pen "a key.”.

Choice C rationale

The parietal lobe processes sensory information related to touch, pain, and spatial awareness. Damage causes difficulty with spatial relations and perception but doesn't typically involve visual misidentification.

Choice D rationale

The occipital lobe handles visual processing. Damage affects vision or visual interpretation but does not impair the recognition or labeling of objects directly.

A. Kaposi's Sarcoma. B. Candidiasis stomatitis. C. Cryptosporidiosis. D. Meningitis.

Correct Answer is A

Explanation

Choice A rationale

Kaposi's Sarcoma is a vascular malignancy associated with AIDS caused by human herpesvirus 8. It presents as purple or brown skin lesions due to abnormal angiogenesis and endothelial proliferation in immunocompromised patients.

Choice B rationale

Candidiasis stomatitis typically manifests as white patches on the mucosa due to fungal overgrowth, not purple or brown spots. It is caused by Candida species, commonly seen in immunosuppressed individuals.

Choice C rationale

Cryptosporidiosis primarily leads to gastrointestinal symptoms such as watery diarrhea due to parasitic infection in AIDS patients, but does not cause purple or brown spots on the skin.

Choice D rationale

Meningitis causes inflammation of the meninges, leading to symptoms like headache, stiff neck, and fever. It does not present with purple or brown lesions on the skin.

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A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.What is the priority action by the nurse?

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Correct Answer is B

Explanation

The patient diagnosed with acquired immunodeficiency syndrome (AIDS) states that they have developed purple, brown spots on their body.Which opportunistic infection does the nurse suspect?

Correct Answer is A

Explanation

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A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.
What is the priority action by the nurse?