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 B

Explanation

A. Respiratory rate, respiratory depth, and pulse oximetry is important for assessing respiratory status, especially postoperatively, but does not directly address fluid volume status, which is the priority nursing problem in this case.

B. After a pancreatoduodenectomy (Whipple procedure), patients are at risk for fluid imbalances due to potential complications such as leakage, infection, or inadequate gastrointestinal absorption. Monitoring abdominal girth, bowel sounds, and NG tube output helps assess fluid volume status and gastrointestinal function.

C. While BUN, creatinine, and weight are valuable in assessing kidney function and fluid status, the immediate postoperative concern is more focused on gastrointestinal function and fluid loss from surgical drainage, rather than renal function alone.

D. Vital signs and cardiac rhythm are important for monitoring overall cardiovascular status, but they do not specifically address the risk of deficient fluid volume as effectively as the assessments in option B, which directly address potential sources of fluid loss.

A. Pancreatic cancers are classified as either endocrine pancreatic cancer or exocrine pancreatic cancer. B. Pancreatic cancer typically develops from a polyp C. The pancreas location increases the risk that cancer will spread into nearby structures and blood vessels D. Pancreatic Cancer is distinguished based on the layers of the pancreas.

Correct Answer is C

Explanation

A. The subdivision of pancreatic tumors into endocrine versus exocrine reflects their cell of origin (islet cells versus ductal cells) rather than conveying information about how the cancer behaves in situ or its propensity for local invasion and metastasis

B. Unlike some other cancers (e.g., colorectal cancer), pancreatic cancer does not typically develop from polyps. Most cases of pancreatic cancer develop from the pancreatic ductal cells (the cells lining the ducts of the pancreas), and the disease is typically aggressive and diagnosed at a later stage.

C. Because the pancreas lies deep in the retroperitoneum directly adjacent to major vessels like the superior mesenteric artery and portal vein, tumors often extend into these structures early, contributing to the high rate of advanced disease at diagnosis

D. Pancreatic cancer is not distinguished based on layers. Instead, it is generally categorized based on the type of cells it affects (e.g., ductal cells in exocrine pancreatic cancer). The staging of pancreatic cancer is based on factors like tumor size, lymph node involvement, and metastasis, rather than the layers of the pancreas.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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