The nurse is caring for a client who has had a head injury. Which of the following assessment information requires the most rapid action by the nurse?
A)The client is more difficult to arouse.
B)The client's pulse is slightly irregular.
C)The client's blood pressure increases from 120/54 to 136/62 mm Hg.
D)The client indicates a headache at pain level 5 of a 10-point scale.

Question

Quizplus · Accepted Answer

The change in level of consciousness (LOC) is an indicator of increased intracranial pressure (ICP) and suggests that action by the nurse is needed to prevent complications. The change in BP should be monitored but is not an indicator of a need for immediate nursing action. Headache is not unusual in a client after a head injury. A slightly irregular apical pulse is not unusual.

The Nurse Is Caring for a Client Who Has Had