The nurse is caring for a patient admitted to the hospital with a fractured femur and possible head injury. Vital signs on admission were blood pressure 128/72 mm Hg, pulse 90 beats/min, and respirations 66 breaths/min
Four hours after admission, the nurse is checking vital signs as part of the hourly assessment. Which of the following vital signs most likely indicate the presence of increased intracranial pressure (ICP)?
a. Blood pressure 172/68 mm Hg, pulse 42 beats/min, respirations 10 breaths/min
b. Blood pressure 160/90 mm Hg, pulse 112 beats/min, respirations 16 breaths/min
c. Blood pressure 130/72 mm Hg, pulse 50 beats/min, respirations 24 breaths/min
d. Blood pressure 100/70 mm Hg, pulse 120 beats/min, respirations 30 breaths/min
ANS: A
Vital sign changes are a late indication of increasing ICP. Cushing's response is a classic late sign of increased ICP. Cushing's response (or Cushing's triad) is characterized by bradycardia, bradypnea, and arterial hypertension (increasing systolic blood pressure while diastolic blood pressure remains the same), resulting in widening pulse pressure.
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1. Identifying one choice as correct to eliminate "none of the above" as a choice. 2. Identifying one choice as incorrect to eliminate "all of the above" as a choice. 3. Not going back and changing an answer once a choice is identified. 4. Going back and reviewing and changing answers as needed once finished with a test. 5. Realizing that most often, the first instinct as to the correct answer is correct.
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