A nurse is caring for a client with a head injury. What sign of rising intracranial pressure should the assigned nurse monitor in such a client?
A) Excessive perspiration
B) Persistent vomiting
C) Falling blood pressure
D) Falling body temperature
B
Feedback:
When caring for a client with a head injury, the nurse should monitor for persistent vomiting as a sign of rising intracranial pressure. The nurse need not monitor for excessive perspiration, falling body temperature, or falling BP in the client: Excessive perspiration is a symptom of fainting. Falling BP is seen in internal bleeding and in late shock. Falling or lowered body temperature is a late sign of hypovolemic shock.
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