A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

Tachycardia.

Hypotension.

Narrowed pulse pressure.

Increasingly severe headache.

Answer and Explanation

The Correct Answer is D

The correct answer is choice d. Increasingly severe headache.

Choice A rationale:

Tachycardia is not typically associated with increased intracranial pressure (ICP). In fact, bradycardia (a slower heart rate) is more commonly seen as part of Cushing’s triad, which indicates increased ICP.

Choice B rationale:

Hypotension is not a common sign of increased ICP. Instead, hypertension (high blood pressure) is often observed as the body attempts to maintain cerebral perfusion pressure.

Choice C rationale:

Narrowed pulse pressure is not a typical indicator of increased ICP. Widened pulse pressure (the difference between systolic and diastolic blood pressure) is more commonly associated with increased ICP.

Choice D rationale:

Increasingly severe headache is a classic symptom of increased ICP. As pressure within the skull rises, it can cause significant pain and discomfort, making this a key indicator to monitor in patients with traumatic brain injury.

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Correct Answer is A

Explanation

Answer is: a. "The estimated blood loss was 250 milliliters."

Explanation: Including the estimated blood loss during the procedure in the hand-off report is relevant information that impacts the patient's care and helps the receiving nurse assess the patient's condition and monitor for complications.

Choice b. is wrong because the client has been transferred to the PACU, it is implied that the intubation has been removed. The focus should be on the patient's current condition and any potential complications related to the procedure.

Choice c. is wrong because the client's role as a member of the board of directors does not directly affect their medical care. Nurses should maintain patient confidentiality and only discuss relevant information regarding the patient's health status.

Choice d. is wrong because the number of sponges used during the procedure is not essential information to include in the hand-off report. The focus should be on the patient's current condition and any potential complications.

A. Self-centered behavior. B. Suspicious of others. C. Callousness. D. Violates others' rights.

Correct Answer is A

Explanation

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A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago. Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

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A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?