What is one of the earliest signs of increased intracranial pressure (ICP)?

Cushing triad.

Decreased level of consciousness (LOC).

Headache.

Coma.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Cushing triad is a late sign of increased ICP, characterized by bradycardia, hypertension, and irregular respirations, appearing after other symptoms like decreased LOC.

Choice B rationale

Decreased LOC is one of the earliest signs of increased ICP as it reflects the brain's response to pressure changes, alerting the need for immediate intervention.

Choice C rationale

Headache can be an early sign but is not as sensitive or specific as changes in LOC when assessing for increased ICP.

Choice D rationale

Coma is a late sign of significantly increased ICP, indicating severe brain dysfunction, often following initial symptoms like decreased LOC.

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Correct Answer is B

Explanation

Choice A rationale

The temporal lobe is primarily responsible for processing auditory information and is involved in memory formation. It plays a crucial role in hearing, language comprehension, and storing visual memories. It is not primarily responsible for abstract thought.

Choice B rationale

The frontal lobe is the largest of the cerebral lobes and is primarily involved in higher cognitive functions such as abstract thought, decision-making, problem-solving, and planning. It also plays a significant role in controlling voluntary movements, speech production, and emotional regulation.

Choice C rationale

The parietal lobe is involved in processing sensory information such as touch, temperature, and pain. It plays a role in spatial orientation and perception, as well as integrating sensory input to form a coherent understanding of the environment. It is not the largest lobe nor the one controlling abstract thought.

Choice D rationale

The occipital lobe is primarily responsible for processing visual information. It interprets visual stimuli from the eyes and helps in recognizing objects, shapes, and colors. It is not involved in abstract thought or higher cognitive functions.

A. Administer a bolus of normal saline as prescribed. B. Administer bronchodilators as prescribed and monitor the client's LOC. C. Increase the client's bed height and reassess in 30 minutes. D. Inform the care team and assess for further signs of possible increased ICP.

Correct Answer is D

Explanation

Choice A rationale

Administering a bolus of normal saline addresses fluid volume but does not directly address the respiratory effort increase or potential increased ICP, which is the most concerning aspect of the head injury.

Choice B rationale

Administering bronchodilators and monitoring LOC may help with respiratory issues but does not address the underlying problem of increased ICP, which could be causing the increased respiratory effort.

Choice C rationale

Increasing the client's bed height and reassessing in 30 minutes might temporarily help, but it is not the most immediate and appropriate intervention. The client’s symptoms suggest a more urgent issue.

Choice D rationale

Informing the care team and assessing for further signs of increased ICP is crucial. Increased respiratory effort in a client with head injury can indicate rising intracranial pressure, which requires immediate medical attention to prevent further complications.

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What is one of the earliest signs of increased intracranial pressure (ICP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which cerebral lobe is the largest and controls abstract thought?

Correct Answer is B

Explanation

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

Correct Answer is D

Explanation

A client who has sustained a head injury cannot identify a familiar object. The nurse knows that this deficit is called which of the following?

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