A patient is in the emergency department following a head injury. The nurse would assess for which sign indicating early increased intracranial pressure?
1. Decreasing level of consciousness
2. Elevated diastolic blood pressure
3. Decreasing respiratory rate
4. Tachycardia
1
Rationale 1: The brain is very sensitive to the level of oxygenation. As the pressure inside the skull increases, hypoxia develops, which negatively affects the level of consciousness.
Rationale 2: A change in blood pressure is generally a widening pulse pressure that would include increased systolic blood pressure.
Rationale 3: A change in respiratory rate is a late sign of increased ICP.
Rationale 4: Bradycardia is the most common indicator of increased ICP.
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True False