When providing care to a patient with increased intracranial pressure, the nurse would be concerned about which clinical finding because it can result in an additional increase in intracranial pressure?
1. Temperature of 99°F (37.2°C)
2. Respiratory rate of 24
3. Serum sodium of 110 mEq/L
4. Blood pressure of 150/65
3
Rationale 1: This is a minor temperature elevation and would not contribute to the patient's increased intracranial pressure.
Rationale 2: This is a minor respiratory rate increase and would not contribute to the patient's increased intracranial pressure.
Rationale 3: Hyponatremia is considered a secondary cause that contributes to increases in intracranial pressure. This laboratory value should be reported and treatment started to avoid additional pressure increases.
Rationale 4: This blood pressure is within parameters that would not affect the patient's cerebral perfusion and is unlikely to contribute to the patient's increased intracranial pressure.
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