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. .

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Decreased level of consciousness. B. Elevated blood pressure and patient reports headache. C. Patient has vomited once and reports persistent nausea. D. Positive Babinski's sign. E. Fever and cardiac dysrhythmias.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

A decreased level of consciousness indicates possible intracranial hemorrhage, a complication of thrombolytic therapy. Altered mental status may result from brain bleeding disrupting normal neural function.

Choice B rationale

Elevated blood pressure and headache suggest intracranial hemorrhage, as the rise in intracranial pressure often accompanies vascular disruption and neurogenic pain.

Choice C rationale

Vomiting and persistent nausea can signal intracranial hemorrhage, as blood irritating brain tissue and increasing pressure stimulates the emetic center in the medulla.

Choice D rationale

Positive Babinski's sign is associated with upper motor neuron lesions but is not a direct indicator of thrombolytic therapy complications such as intracranial bleeding.

Choice E rationale

Fever and cardiac dysrhythmias do not directly indicate thrombolytic therapy complications. Dysrhythmias may stem from electrolyte disturbances or infections unrelated to hemorrhage.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient presents to the emergency department with a cervical spinal cord injury immediately after a motor vehicle accident.What should the nurse explain to the family as the reason for the patient being placed on mechanical ventilation? The:

Correct Answer is A

Explanation

The nurse is caring for a client who has had a stroke and who has received tissue plasminogen activator (t-P

Correct Answer is ["A","B","C"]

Explanation

The nurse is caring for a patient with epilepsy who has recently had a change in their prescribed medication combination.Which of the following options are priority to institute?

The nurse should educate clients who are HIV+ on proper nutrition, exercise, and stress reduction because these factors will: (Select All that Apply.)

The nurse is caring for a trauma patient with a suspected brain injury and Battle's Sign.The nurse notices a yellow stain around fluid dripping from the patient's ear.The nurse's priority intervention will be as follows:

The nurse is preparing to turn the patient who sustained a spinal cord injury.How should the nurse proceed?

The nurse is caring for a patient in the acute care setting with a spinal cord injury at the level of C-3. The nurse understands that the main cause of complications or death related to this injury includes:

The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior.What would be the best response by the nurse?

The nurse is performing an admission assessment on a client with a diagnosis of detached retina.Which of the following is associated with this eye disorder?

A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.The patient complains of feeling dizzy and is diaphoretic.What would be the priority nursing action?

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)?