Admission vital signs for a brain-injured patient are blood pressure 128/68,pulse 110,and respirations 26.Which set of vital signs,if taken 1 hour after admission,will be of most concern to the nurse?

Question

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Systolic hypertension with widening pulse pressure,bradycardia,and respiratory changes represent Cushing's triad.These findings indicate that the intracranial pressure (ICP)has increased,and brain herniation may be imminent unless immediate action is taken to reduce ICP.The other vital signs may indicate the need for changes in treatment,but they are not indicative of an immediately life-threatening process.

Admission Vital Signs for a Brain-Injured Patient Are Blood Pressure