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 C

Explanation

Choice A rationale

Soft restraints are utilized for agitation but are not prioritized in epilepsy care. Emergency equipment like suction ensures airway safety during seizures.

Choice B rationale

Glasgow Coma Scale evaluates neurological function but is less relevant for epilepsy management compared to essential tools like suction equipment for airway protection.

Choice C rationale

Suction equipment and oxygen are vital in epilepsy management to clear secretions and maintain oxygenation during seizures. Patent IV access allows rapid administration of emergency medications.

Choice D rationale

Dextrose infusion is used to treat hypoglycemia rather than seizures. Epilepsy care prioritizes tools like suction and oxygen for immediate seizure-related complications. .

Correct Answer is ["66.7"]

Explanation

Step 1 is (1600 mL ÷ 24 hours).

Answer is 66.7 mL/hr.

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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

The nurse is caring for a patient with epilepsy who has recently had a change in their prescribed medication combination.Which of the following options are priority to institute?

Correct Answer is C

Explanation

The nurse is preparing to administer 1600 mL of total parental nutrition (TPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr?

Correct Answer is ["66.7"]

Explanation

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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)?