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 D

Explanation

A. Abnormal sensory sensations such as tingling may be associated with the aura phase of a seizure but are not typically observed postictally.

B. Yellowing of the skin is usually indicative of jaundice, unrelated to seizure activity or the postictal state.

C. Itching of the eyes is unrelated to seizure activity and would not typically be documented in the context of postictal observations.

D. The postictal state is characterized by drowsiness, confusion, and other altered mental statuses that follow a seizure. This period can vary in duration depending on the patient and seizure type.

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

Correct Answer is A

Explanation

A. Kaposi's Sarcoma is a cancer commonly associated with AIDS, characterized by purple or brown lesions on the skin and mucous membranes. It is linked to human herpesvirus-8 (HHV-8) and is often seen in immunocompromised individuals.

B. Candidiasis stomatitis involves oral or esophageal thrush, presenting as white patches rather than purple or brown lesions.

C. Cryptosporidiosis is a parasitic infection causing severe diarrhea but does not manifest as skin lesions.

D. Meningitis can cause neurological symptoms and systemic infection but does not present with purple or brown skin spots.

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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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