Difficulty: Medium
Average Score: 73%
Simulated
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)?
Correct answer
A
Rationale
Altered mental status, such as confusion, restlessness, or lethargy, is often the earliest sign of increasing ICP as it reflects brain tissue compression.