The nurse is caring for a client with an acute head injury. Which assessment finding would first alert the nurse that the client is developing an Increase in intracranial pressure?

Widening pulse pressure

Increasing restlessness

Decrease in the pulse rate

Dilated fixed pupils

Answer and Explanation

The Correct Answer is B

A. A widening pulse pressure (the difference between systolic and diastolic blood pressure) can be a sign of increasing intracranial pressure (ICP), but it typically occurs later in the progression of ICP. Early signs of increased ICP are often more subtle and include changes in behavior and consciousness.

B. One of the earliest signs of increased ICP is altered mental status or behavioral changes, such as increasing restlessness or agitation. As pressure builds inside the skull, it affects the brain's ability to function normally, leading to these early signs. Restlessness may indicate that the brain is becoming less able to maintain normal function due to the increasing pressure.

C. A decrease in pulse rate may occur later in the course of increased ICP, particularly with severe increases in pressure. However, early signs typically involve changes in consciousness and mental status rather than changes in vital signs like heart rate.

D. Dilated and fixed pupils are a late sign of increased ICP and usually indicate significant brain herniation or severe neurological compromise. While they are serious and require immediate attention, they do not typically occur at the early stages of increased ICP.

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Correct Answer is A

Explanation

A. Assessing site daily for redness, swelling, or exudate at insertion site is crucial for detecting early signs of infection. A tunneled IV catheter, like a Hickman catheter, provides a direct route to the bloodstream, so infection at the insertion site can lead to serious complications such as sepsis. Regular monitoring is essential.
B. The catheter should be flushed regularly, but the standard protocol is usually to flush the catheter with saline or heparin more frequently (often every 7 days or after each use) and with a larger syringe (typically 10 mL) to prevent catheter damage. The frequency and method of flushing should be confirmed with institutional protocols and the healthcare provider.
C. Swelling in the neck or arm could indicate a complication like thrombosis or catheter occlusion, and it is important to notify the healthcare provider. However, this is not directly related to infection, so it's a more specific symptom rather than a broad teaching point about infection signs.
D. While the healthcare provider may monitor various lab values, the focus of teaching about infection would not be on hemoglobin and hematocrit. The main concern post-placement of a Hickman catheter is the risk of infection, not necessarily these specific lab values.

A. D-dimer fibrinogen and fibrin degradation products B. Complete blood count, platelets and prothrombin time C. Prothrombin time fibrin level and D-dimer D. Fibrin degradation products, lactic acid and complete blood count

Correct Answer is A

Explanation

A. The diagnostic workup for disseminated intravascular coagulation (DIC) typically includes the measurement of D-dimer, fibrinogen, and fibrin degradation products. D-dimer levels are elevated in DIC due to increased fibrin breakdown, and fibrinogen levels are usually decreased due to consumption. Fibrin degradation products (FDPs) are also elevated in DIC and provide evidence of abnormal clotting and fibrinolysis.

B. While a complete blood count (CBC) and platelet count are part of the evaluation of DIC, they are not sufficient on their own to confirm the diagnosis. The prothrombin time (PT) is helpful but does not provide the most specific information regarding fibrinolysis and clot breakdown, which are crucial in diagnosing DIC.

C. While prothrombin time (PT) and D-dimer are useful in the diagnosis of DIC, fibrin level is not a standard test. The focus is generally on fibrinogen and fibrin degradation products (FDPs) rather than fibrin levels.

D. Although fibrin degradation products and a complete blood count are part of the evaluation, lactic acid is not typically a key test in diagnosing DIC. Lactic acid levels may rise in conditions associated with hypoperfusion or shock but do not specifically diagnose DIC.

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The nurse is caring for a client with an acute head injury. Which assessment finding would first alert the nurse that the client is developing an Increase in intracranial pressure?

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