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)?

T98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air.

T92.5 F (33.6 C), BP 90/64, HR 80, RR 14, O2 Sat 97% Room Air.

T103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air.

T98.6 F (37 C), BP 200/94, HR 90, RR 18, O2 Sat 100% Room Air.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Extremely high systolic BP (220 mmHg), bradycardia (HR 30), and altered respirations (RR 6) suggest Cushing's triad, a hallmark of increased ICP due to severe brain injury.

Choice B rationale

Hypothermia (T92.5°F) and hypotension (BP 90/64) do not indicate increased ICP but may result from shock or hypothermic conditions affecting autonomic responses.

Choice C rationale

Hyperthermia (T103.1°F) and tachycardia (HR 132) are commonly seen in infection or hypermetabolic states, not directly pointing to raised ICP.

Choice D rationale

Mild hypertension (BP 200/94) with normal HR (90) and RR (18) does not fit the classic signs of increased ICP like Cushing's triad.

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Correct Answer is B

Explanation

Choice A rationale

Susceptible host pertains to the individual's vulnerability to an infectious agent, but handwashing targets the mode of transmission rather than addressing susceptibility or the infectious agent directly.

Choice B rationale

Handwashing interrupts the mode of transmission, preventing pathogens from reaching a portal of entry. This action disrupts the chain of infection and reduces pathogen spread effectively.

Choice C rationale

The infectious agent and reservoir focus on pathogen origination rather than its transfer. Handwashing reduces spread but does not directly address pathogen survival within reservoirs.

Choice D rationale

Portal of exit involves the pathogen leaving the host's body, not its transfer. Handwashing reduces pathogen transmission, specifically addressing its ability to reach a new host.

A. Decreased level of consciousness. B. Elevated blood pressure and patient reports headache. C. Patient has vomited once and reports persistent nausea. D. Positive Babinski's sign. E. Fever and cardiac dysrhythmias.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

A decreased level of consciousness indicates possible intracranial hemorrhage, a complication of thrombolytic therapy. Altered mental status may result from brain bleeding disrupting normal neural function.

Choice B rationale

Elevated blood pressure and headache suggest intracranial hemorrhage, as the rise in intracranial pressure often accompanies vascular disruption and neurogenic pain.

Choice C rationale

Vomiting and persistent nausea can signal intracranial hemorrhage, as blood irritating brain tissue and increasing pressure stimulates the emetic center in the medulla.

Choice D rationale

Positive Babinski's sign is associated with upper motor neuron lesions but is not a direct indicator of thrombolytic therapy complications such as intracranial bleeding.

Choice E rationale

Fever and cardiac dysrhythmias do not directly indicate thrombolytic therapy complications. Dysrhythmias may stem from electrolyte disturbances or infections unrelated to hemorrhage.

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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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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)?