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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased intracranial pressure (ICP) typically causes hypertension (increased blood pressure) rather than hypotension.
B. A decreased level of consciousness is one of the hallmark signs of increased ICP, as pressure on the brainstem affects consciousness.
C. Tachypnea may occur with ICP, but it is less specific compared to decreased consciousness.
D. This can occur with brain injury but is not as directly indicative of ICP as decreased consciousness.
Correct Answer is D
Explanation
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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