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)?
Restlessness and altered mental status.
Widening pulse pressure.
Fixed and dilated pupils.
Tachycardia and hypotension.
The Correct Answer is A
Choice A rationale
Restlessness and altered mental status are early signs of increasing intracranial pressure, resulting from cerebral edema compressing neural tissue and reducing oxygen supply to critical brain regions.
Choice B rationale
Widening pulse pressure is a later sign of increased intracranial pressure, indicating significant disruption of autonomic regulation and brainstem function. Early symptoms like restlessness occur first.
Choice C rationale
Fixed and dilated pupils signify severe and advanced intracranial pressure, often indicating brain herniation, which is a critical stage beyond initial compensatory mechanisms.
Choice D rationale
Tachycardia and hypotension are not hallmark signs of raised intracranial pressure. Bradycardia and hypertension align more closely with Cushing's triad, associated with late-stage intracranial hypertension. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.
Choice B rationale
Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.
Choice C rationale
Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.
Choice D rationale
Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.
Correct Answer is C
Explanation
Choice A rationale
Sleeping on the operative side increases pressure on the eye, risking complications like increased intraocular pressure and disrupted healing of surgical incisions. Postoperative care avoids this positioning.
Choice B rationale
Lifting items over 5-10 pounds risks increased intraocular pressure. Guidelines usually limit lifting to light objects, not 30 pounds. Heavy lifting can cause strain affecting surgical recovery.
Choice C rationale
Eye shields protect the operative site during sleep, preventing accidental trauma, while glasses shield from debris during daytime. These preventive measures support proper healing and recovery post-cataract surgery.
Choice D rationale
Avoiding eye drops disrupts healing as prescribed medications manage inflammation and prevent infections after surgery. Proper use of eye drops supports post-surgical recovery effectively.
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