The nurse is caring for a patient with a head injury.Over a time span of 30 minutes,the nurse observes the following vital signs changes: temperature from 97° to 98° F; pulse from 86 to 78 beats/min; respirations from 18 to 14 breaths/min; and blood pressure from 140/86 to 150/82.Which action is most important for the nurse to take?

Question

Quizplus · Accepted Answer

An increasing temperature,decreasing pulse and respirations,and a widening pulse pressure are indicative of increasing intracranial pressure (ICP).Any identified change must be reported to the provider promptly.The nurse should also observe the pupils for any changes,determine the patient's GCS score,and document the findings.

The Nurse Is Caring for a Patient with a Head