The nurse caring for a patient with increased intracranial pressure (ICP) would be correct in assessing for which of the following early clinical manifestations?
A) Disorientation and restlessness
B) Decreased pulse and respirations
C) Projectile vomiting
D) Loss of corneal reflex
Ans: A
Feedback: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.
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a. "Do you have any allergies?" b. "When was your last bowel movement?" c. "Do you tend to be claustrophobic?" d. "Are you sexually active?"