Admission vital signs for a brain-injured patient are blood pressure 128/68, pulse 110, and respi-rations 26. Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 154/68, pulse 56, respira-tions 12
b. Blood pressure 134/72, pulse 90, respira-tions 32
c. Blood pressure 148/78, pulse 112, respira-tions 28
d. Blood pressure 110/70, pulse 120, respira-tions 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes repre-sent Cushing's triad. These findings indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an im-mediately life-threatening process.
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