The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

BP 190/84, HR 50, and an irregular respiratory pattern

BP 190/84, HR 150, and an irregular respiratory pattern

BP 80/50, HR 50, and Kussmaul respirations

BP 80/50, HR 150, and Cheyne-Stokes respirations

Answer and Explanation

The Correct Answer is A

A. BP 190/84, HR 50, and an irregular respiratory pattern is characteristic of Cushing's triad, a classic sign of increased intracranial pressure (ICP). Cushing's triad includes hypertension with a widened pulse pressure, bradycardia, and irregular or abnormal respirations. The elevated blood pressure occurs as a compensatory mechanism to maintain cerebral perfusion, while bradycardia and irregular respirations result from brainstem compression.

B. BP 190/84, HR 150, and an irregular respiratory pattern is incorrect because tachycardia (HR 150) is not part of Cushing's triad. Increased ICP typically causes bradycardia due to brainstem involvement.

C. BP 80/50, HR 50, and Kussmaul respirations: Kussmaul respirations are deep, rapid respirations commonly seen in metabolic acidosis, not typically associated with increased intracranial pressure.
D. BP 80/50, HR 150, and Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by alternating periods of deep breathing followed by apnea and are often seen in conditions affecting the brainstem, but they are not specific to increased intracranial pressure.

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Correct Answer is A

Explanation

A. Restlessness: Restlessness is a common early sign of increased intracranial pressure (ICP) in clients with traumatic brain injury. It can result from discomfort, confusion, or agitation due to pressure on the brain.

B. Amnesia: Amnesia, or memory loss, can occur with traumatic brain injury but is not specifically indicative of increased intracranial pressure.

C. Tachycardia: Tachycardia may occur in response to various factors such as pain, stress, or fever, but it is not a specific indicator of increased intracranial pressure.

D. Hypotension: Hypotension (low blood pressure) is not typically associated with increased intracranial pressure. In fact, hypertension (high blood pressure) may be a compensatory response to maintain cerebral perfusion pressure in the setting of elevated ICP.

A. Confusion B. Aphasia C. Pain D. Falls

Correct Answer is D

Explanation

A. Confusion: While confusion may occur in some neurological conditions, it is not directly associated with a positive Romberg test result.

B. Aphasia: Aphasia refers to difficulty with language and communication and is typically associated with brain injury or stroke, not with a positive Romberg test result.

C. Pain: Pain is not directly assessed by the Romberg test. However, a positive Romberg test result may indicate sensory ataxia, which can contribute to difficulty with proprioception and coordination, potentially leading to increased risk of injury and pain.

D. Falls: A positive Romberg test result indicates impaired proprioception and balance,
increasing the risk of falls, especially in older adults or individuals with neurological conditions. This is the expected problem associated with a positive Romberg test result.

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The nurse anticipates that the client presenting with increased intracranial pressure would most likely exhibit which set of vital signs?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Correct Answer is A

Explanation

Which problem should the nurse expect for a patient who has a positive Romberg test result?

Correct Answer is D

Explanation

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