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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Conjunctivitis (pink eye) is not a typical complication of Bell's Palsy.
B. Retinal detachment is unrelated to the incomplete eye closure seen in Bell’s Palsy.
C. Bell's Palsy often results in incomplete eye closure, which can lead to drying and irritation of the cornea, increasing the risk for corneal abrasions. An eye patch protects the cornea by helping the eye stay moist and protected from injury.
D. A chalazion is a small eyelid bump caused by blocked oil glands, not associated with Bell’s Palsy.
Correct Answer is C
Explanation
A. Soft restraints are not recommended during a seizure and can cause harm to the patient.
B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.
C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.
D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.
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