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

A. Ask the client for permission to take photographs. B. Provide community sexual assault support contacts. C. Document the client's verbatim statements. D. Determine any physical signs of injury.

Correct Answer is D

Explanation

The correct answer is choice d. Determine any physical signs of injury.

Choice A rationale:

Asking the client for permission to take photographs is important for forensic evidence, but it should not be the first action. The nurse must first ensure the client’s immediate physical well-being.

Choice B rationale:

Providing community sexual assault support contacts is crucial for the client’s long-term support and recovery, but it is not the immediate priority in an emergency assessment.

Choice C rationale:

Documenting the client’s verbatim statements is essential for legal and medical records, but it should follow the initial physical assessment to address any urgent medical needs.

Choice D rationale:

Determining any physical signs of injury is the first priority. This ensures that any immediate medical needs are addressed, which is critical for the client’s safety and well-being.

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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?