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 C

Explanation

Choice A rationale

Asking the patient why they are behaving inappropriately does not address or stop the behavior. This approach may escalate the situation, leading to further discomfort for others.

Choice B rationale

Recommending 1: observation without addressing the behavior does not teach social boundaries. It is a passive solution that misses the opportunity for behavior correction.

Choice C rationale

Pointing out the behavior as unacceptable sets clear boundaries and educates the patient on appropriate social conduct. It creates an opportunity for the patient to reflect and adjust their behavior.

Choice D rationale

Having the patient return to their room may temporarily stop the behavior but does not educate the patient or reinforce appropriate boundaries for public settings.

A. Kaposi's Sarcoma. B. Candidiasis stomatitis. C. Cryptosporidiosis. D. Meningitis.

Correct Answer is A

Explanation

Choice A rationale

Kaposi's Sarcoma is a vascular malignancy associated with AIDS caused by human herpesvirus 8. It presents as purple or brown skin lesions due to abnormal angiogenesis and endothelial proliferation in immunocompromised patients.

Choice B rationale

Candidiasis stomatitis typically manifests as white patches on the mucosa due to fungal overgrowth, not purple or brown spots. It is caused by Candida species, commonly seen in immunosuppressed individuals.

Choice C rationale

Cryptosporidiosis primarily leads to gastrointestinal symptoms such as watery diarrhea due to parasitic infection in AIDS patients, but does not cause purple or brown spots on the skin.

Choice D rationale

Meningitis causes inflammation of the meninges, leading to symptoms like headache, stiff neck, and fever. It does not present with purple or brown lesions on the skin.

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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)?