The vital signs for a client with a possible head injury were on admission: blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min
Which vital sign assessment conducted four hours later most likely indicates the presence of increased intracranial pressure (ICP)?
a. Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min
b. Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/min
c. Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/min
d. Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min
ANS: A
Vital sign changes are a late indication of increasing ICP. Cushing's response is a classic late sign of increased ICP. Cushing's response (or Cushing's triad) is characterized by bradycardia, bradypnea, and arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same), resulting in widening pulse pressure. B. These vital signs indicate tachycardia. C. These vital signs indicate tachypnea. C. These vital signs indicate both tachycardia and tachypnea.
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