The nurse is providing care for a client with a head injury and wants to decrease the client's risk for developing increased intracranial pressure (IICP). Which assessment data indicates that the nurse is successful?

Question

Quizplus · Accepted Answer

A)Assessment areas include level of consciousness (LOC); behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. A sluggish response to verbal stimuli could indicate increasing ICP.
B)Assessment areas include level of consciousness (LOC); behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. A sluggish response to verbal stimuli could indicate increasing ICP.
C)Assessment areas include level of consciousness (LOC); behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. A sluggish response to verbal stimuli could indicate increasing ICP.
D)Assessment areas include level of consciousness (LOC); behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. A sluggish response to verbal stimuli could indicate increasing ICP.

The Nurse Is Providing Care for a Client with a Head