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)?

T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air

T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air

T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air

T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Answer and Explanation

The Correct Answer is B

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"D"},"C":{"answers":"B"},"D":{"answers":"C"}}

Explanation

Macular degeneration: This condition leads to the loss of central vision due to damage to the macula, which is responsible for sharp, straight-ahead vision.

Presbyopia: A common age-related condition resulting in a gradual loss of near visual acuity as the lens becomes less flexible, making it harder to focus on close objects.

Glaucoma: Typically causes loss of peripheral vision due to increased intraocular pressure damaging the optic nerve, eventually leading to tunnel vision if untreated.

Cataracts: Causes blurry vision as the lens becomes clouded, leading to general visual disturbance that progresses over time.

A. Elevate the head of the bed, loosen clothing, and check the urinary catheter for obstruction B. Elevate the head of the bed and apply a cool compress to the forehead C. Place in Semi-Fowler's position and establish IV access D. Establish IV access, apply 2 liters of nasal oxygen, and contact the health care provider

Correct Answer is A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

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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)?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"D"},"C":{"answers":"B"},"D":{"answers":"C"}}

Explanation

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Correct Answer is A

Explanation

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