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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Fluid intake does not directly impact intraocular pressure. Management of glaucoma focuses on medications like eye drops and surgical interventions rather than restricting fluid intake.
Choice B rationale
Glaucoma treatments, including eye drops, aim to manage intraocular pressure. These medications are required lifelong to prevent optic nerve damage and preserve vision.
Choice C rationale
Excess salt impacts systemic blood pressure but does not directly influence intraocular pressure. Glaucoma management targets ocular pressure, not dietary sodium reduction.
Choice D rationale
Avoiding eye overuse may reduce strain but does not address intraocular pressure. Effective glaucoma treatment relies on pharmacological or surgical measures rather than activity limitation.
Correct Answer is B
Explanation
Choice A rationale
The frontal lobe controls executive functions like reasoning and planning, not object identification errors. Damage here leads to issues with decision-making and voluntary movement, not misidentification of objects.
Choice B rationale
The temporal lobe processes auditory information and object recognition. Injury disrupts the brain's ability to associate visual stimuli with correct labels, causing errors like calling a pen "a key.”.
Choice C rationale
The parietal lobe processes sensory information related to touch, pain, and spatial awareness. Damage causes difficulty with spatial relations and perception but doesn't typically involve visual misidentification.
Choice D rationale
The occipital lobe handles visual processing. Damage affects vision or visual interpretation but does not impair the recognition or labeling of objects directly.
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