A patient's initial assessment revealed blood pressure 128/70, pulse 68, respirations 20, and pupils equal and reactive. The patient is awake and responding to verbal stimuli but demonstrating weakness on the left side

Question

A medical diagnosis is presumptive stroke. Two hours later the patient is not awake but is easily aroused, has a blood pressure of 140/70, pulse 52, respirations 18, and the left pupil now reacts more slowly to light than the right pupil. Which complication is likely to have occurred? 1. Reperfusion injury
2. Normal stabilization poststroke
3. Increased intracranial pressure
4. Impending brain death

Answer 1

3
Rationale 1: Reperfusion injury results in further injury to already damaged tissue that is compromised and may be seen most often with thrombolytic therapy. There is no indication that this patient has had thrombolytic therapy.
Rationale 2: The most current assessment findings indicate that the patient's condition is becoming more unstable.
Rationale 3: Rising systolic blood pressure, falling pulse, and a pupil that has become sluggish suggest increasing intracranial pressure (IICP) and requires notification of the health care provider.
Rationale 4: Brain death is diagnosed by a lack of brain waves and inability to maintain vital function.