The nurse is caring for a 3-year-old with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)?
a. Temperature increase from 37.2 ° C (99 ° F) to 37.7 ° C (100 ° F)
b. Increase in blood pressure with an attendant decrease in pulse
c. Increase in respirations
d. Equilateral pupils
ANS: B
Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.
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Your client is a Native American. His appointment with you is scheduled for 1:00 on Tuesday. You expect him to arrive
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