The nurse is caring for a client with a head injury and has admission vital signs of blood pressure 128/68 mm Hg, pulse 110 beats/minute, and respirations 26/minute. Which of these vital signs, if taken 1 hour after admission, will be of most concern tothenurse?
A)Blood pressure 156/60, pulse 55, respirations 12
B)Blood pressure 130/72, pulse 90, respirations 32
C)Blood pressure 148/78, pulse 112, respirations 28
D)Blood pressure 110/70, pulse 120, respirations 30

Question

Quizplus · Accepted Answer

Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing's triad and 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.

The Nurse Is Caring for a Client with a Head