The blood pressure of a patient with a traumatic brain injury increases from 130/60 to 170/65 mm Hg. How should the nurse respond to this change in blood pressure?

Question

Quizplus · Accepted Answer

1. This change in blood pressure is not due to fluid volume overload.
2. Autoregulation is the ability of the brain to maintain a constant perfusion despite wide variations in blood pressures. When systemic blood pressure is too high, cerebral vessels constrict and maintain normal cerebral blood flow. When systemic blood pressure is more than 160 mm Hg, and when cerebral perfusion drops below a minimum level, autoregulation is not effective. The nurse needs to assess the impact of the increased blood pressure on the patient's neurologic status by completing a neurologic assessment.
3. The nurse would need to assess the patient's neurologic status before contacting the physician for treatment.
4. The nurse needs to first assess the patient's neurologic status before medicating for pain or anxiety since these types of medications will dampen neurologic responses.

The Blood Pressure of a Patient with a Traumatic Brain