Following a motorcycle accident, a client is brought to the emergency department with multiple fractures
Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? A) Blood pressure 100/60 mm Hg
B) Lethargy
C) Nausea
D) Periorbital edema
B
Feedback:
Decreasing level of consciousness is one of the earliest signs of increased ICP. Without a baseline for the BP, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Perioribital edema is more suggestive of fluid overload than ICP.
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