A patient who has suffered a traumatic brain injury has his blood pressure increase from 130/60 to 170/65 mm Hg. The nurse should respond to this increase in blood pressure by:
1. Weighing the patient to determine if the patient is fluid overloaded
2. Documenting the blood pressure and completing a neurologic assessment
3. Alerting the physician and preparing to administer an antihypertensive agent
4. Providing the patient with immediate pain and/or antianxiety medication
2
Rationale 1: This change in blood pressure is not due fluid volume overload.
Rationale 2: Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. The nurse needs to assess the impact of the increased blood pressure on the patient's neurologic status by completing a neurologic assessment.
Rationale 3: The nurse would need to assess the patient's neurologic status before contacting the physician for treatment.
Rationale 4: The nurse needs to first assess the patient's neurologic status before medicating for pain or anxiety since these types of medications will dampen neurologic responses.
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