A patient is in the emergency department following a head injury. What should the nurse realize as being the most accurate sign of developing increased intracranial pressure (IICP)?
1. decreasing level of consciousness
2. elevated diastolic blood pressure
3. decreasing respiratory rate
4. pupils are equal
Correct Answer: 1
The brain is very sensitive to the level of oxygenation. As hypoxia develops, it will negatively affect the level of consciousness. Change in blood pressure is generally a widening pulse pressure. Change in respiratory rate is a late sign of IICP. Size, shape, and responsiveness of the pupils, not simply equality, should be assessed to determine if ICP is increasing.
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