A patient is admitted to the hospital after a head injury. The nurse notes a widening pulse pressure. Which of the following actions is most appropriate?
a. None; this is an expected finding after a head injury.
b. Lay the bed flat and check pupil response.
c. Raise the head of the bed and notify the RN.
d. Give an extra dose of diuretic.
ANS: C
Widening pulse pressure or falling blood pressure are signs of increased intracranial pressure (ICP) and should be reported promptly. Raising the head of the bed 30 degrees may help reduce ICP. Increased ICP is not unexpected, but it is not normal and must be reported. A diuretic would only be given with a physician's order.
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