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

Non-tender lymph nodes and productive cough are more suggestive of later-stage infections or malignancies, not early HIV presentation which resembles acute viral syndrome.

Choice B rationale

Flu-like symptoms such as chills and aches occur during acute retroviral syndrome due to initial viral replication and immune response shortly after HIV infection.

Choice C rationale

Abdominal cramping and loose stools are associated with gastrointestinal infections in later stages of HIV due to opportunistic pathogens, not acute early-stage presentation.

Choice D rationale

High fever, severe headache, and change in mentation are indicative of central nervous system infections or complications in advanced HIV stages, not early acute HIV symptoms.

A. Administer 40 ounces of fruit juice. B. Administer 15 grams of simple carbohydrates in the form of hard candy. C. Administer 50 mL of Dextrose 50% IV push. D. Repeat the blood glucose test after 15 minutes.

Correct Answer is C

Explanation

Choice A rationale

Administering 40 ounces of fruit juice would result in excessive carbohydrate intake and is inappropriate for treating hypoglycemia. Standard treatment includes 15 grams of carbohydrates or intravenous glucose for severe symptoms.

Choice B rationale

Hard candy provides 15 grams of carbohydrates, suitable for a patient who is alert and able to safely swallow. However, this client exhibits confusion and lethargy, necessitating a quicker, safer IV intervention.

Choice C rationale

Administering Dextrose 50% IV push rapidly raises blood glucose levels, effectively treating hypoglycemia in symptomatic, confused, or unconscious patients. This intervention bypasses the gastrointestinal tract for immediate action.

Choice D rationale

Rechecking glucose after 15 minutes is essential after treatment but does not address acute hypoglycemia. Delaying treatment risks prolonged hypoglycemia, increasing the risk of neuronal injury or further clinical deterioration. .

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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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Correct Answer is B

Explanation

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Correct Answer is C

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)?