When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min

BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min

BP 172/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

Answer and Explanation

The Correct Answer is D

A.   BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B.   BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C.   BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D.   The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Sitting at a 30° angle is not optimal for eating. The client should sit upright at a 90° angle to ensure safe swallowing.
B. Tilting the head forward while swallowing helps promote a safer swallow and reduces the risk of aspiration.
C. Coughing while swallowing is not a recommended strategy unless there is aspiration, and it does not address prevention of dysphagia.
D. Placing food on the weaker side of the mouth is not recommended. The food should be placed on the stronger side to improve swallowing safety.

A. Decreasing Glasgow Coma scores B. Swelling of the optic nerve C. Respiratory rate of 12/min D. Changes to pupil size and shape E. Blood pressure of 108/74 mm Hg

Correct Answer is ["A","B","D"]

Explanation

A. Decreasing Glasgow Coma scores indicate a worsening neurological status and reduced consciousness.
B. Swelling of the optic nerve (papilledema) is a sign of increased ICP and indicates worsening conditions.
C. A respiratory rate of 12/min may be within normal range for some individuals but can also be a sign of impending respiratory depression in cases of severe ICP. However, it is not as immediately concerning as the other options in this case.
D. Changes in pupil size and shape are classic signs of worsening ICP. Unequal or nonreactive pupils are a key indicator.
E. Blood pressure of 108/74 mm Hg is not concerning unless it represents a significant drop from the baseline; other signs of worsening ICP are more critical in this case.

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When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the partner of a client who had a stroke about dysphagia. Which of the following statements by the client's partner should indicate to the nurse that the teaching was effective?

Correct Answer is B

Explanation

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

Correct Answer is ["A","B","D"]

Explanation

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When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

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