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.

Answer and Explanation

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. .

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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. Hold the feeding if the client has soft brown stools and is passing flatus. B. Dilute each medication with 5% dextrose in water (D5W) and flush with at least 30 mL. C. Discuss the order with the prescriber if the client's abdomen is distended with hypoactive bowel sounds and RLQ tenderness. D. Check for residual enteral formula prior to administration.

Correct Answer is C

Explanation

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

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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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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)?