The nurse is caring for a patient who has a head injury and fractured right arm after being as-saulted. Which assessment information requires the most rapid action by the nurse?
a. The apical pulse is slightly irregular.
b. The patient complains of a headache.
c. The patient is more difficult to arouse.
d. The blood pressure (BP) increases to 140/62 mm Hg.
ANS: C
The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache and a slightly irregular apical pulse are not unusual in a patient after a head injury.
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