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 A
Explanation
Choice A rationale
Cervical spinal cord injuries at or above C3 disrupt the phrenic nerve, impairing diaphragm control, leading to respiratory failure. Mechanical ventilation compensates for the loss of neural signals required for effective breathing.
Choice B rationale
Unconsciousness alone does not necessitate ventilation unless breathing is compromised. Here, respiratory failure stems from cervical nerve injury, not loss of consciousness, requiring mechanical support.
Choice C rationale
The lungs themselves are not damaged in cervical spinal cord injuries; the issue lies in disrupted nerve signals needed for diaphragm and respiratory muscle function, necessitating ventilatory assistance.
Choice D rationale
Smoking history does not explain the acute respiratory failure caused by cervical spinal cord injuries. The need for ventilation directly results from damage to the neural control of respiratory muscles.
Correct Answer is C
Explanation
Choice A rationale
The latent period of HIV includes asymptomatic phases when the CD4+ count remains above 200 cells/mm. Pneumocystic pneumonia and low CD4+ counts signify progression beyond latent HIV.
Choice B rationale
HIV-positive status reflects infection presence, but it does not confirm AIDS unless CD4+ count drops below 200 cells/mm and opportunistic infections occur, such as pneumocystic pneumonia.
Choice C rationale
AIDS is diagnosed when CD4+ count decreases below 200 cells/mm, coupled with opportunistic infections. Pneumocystic pneumonia indicates a weakened immune system due to advanced disease.
Choice D rationale
Seroconversion marks the initial immune response to HIV infection with detectable antibodies but occurs before CD4+ counts decline significantly and opportunistic infections appear.
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