The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?

Altered mental status

Tachycardia and hypotension

Fixed and dilated pupils

Widening pulse pressure

Answer and Explanation

The Correct Answer is A

A. Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.

B. Tachycardia and hypotension are not primary indicators of elevated ICP.

C. Fixed and dilated pupils indicate severe and often irreversible ICP increase, occurring later in the progression.

D. Widening pulse pressure is a later sign of increased ICP, following changes in mental status.

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Correct Answer is C

Explanation

A. Avoiding sexual intercourse under the influence of drugs reduces certain risks but does not address the specific risk of needle transmission.

B. Asking others to be tested for HIV may be unrealistic and does not prevent HIV transmission through shared equipment.

C. Participating in a needle exchange program reduces the risk of HIV transmission by providing sterile needles, lowering the likelihood of infection from shared or contaminated needles.

D. Cleaning needles with betadine is not effective for HIV prevention; only sterile, unused needles should be used.

A. Anticipate a medical prescription for a hearing test B. Obtain a culture of the drainage C. Remove any foreign body from the ear canal D. Obtain a medical prescription for a CT of the skull

Correct Answer is B

Explanation

A. A hearing test does not address the infection symptoms and would not be the priority.

B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.

C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.

D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.

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The nurse is caring for a patient with an acute head injury. Which assessment finding would first alert the nurse that the patient is developing an increase in intracranial pressure (ICP)?

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