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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Correct Answer is C

Explanation

A. An ICP of 10 mm HG is within normal limits.
B. An ICP of 15 mm HG is within normal limits.
C. An ICP of 20 mm Hg is elevated and should be reported immediately as it can indicate worsening conditions like brain swelling or herniation. Normal ICP is typically 5 to 15 mm Hg.
D. An ICP of 5 mm HG is also normal and would not require immediate reporting.

A. Glucose level, BP, and brain tissue B. BP, brain tissue, and cerebrospinal fluid C. BP, brain tissue, body mass index D. BP, brain tissue, and ventricles of the brain

Correct Answer is B

Explanation

A. Glucose level, BP, and brain tissue: Glucose level is not a key component of ICP balance.
B. BP, brain tissue, and cerebrospinal fluid: These are the primary components that contribute to ICP balance. Changes in any of these can affect pressure inside the skull.
C. BP, brain tissue, body mass index: BMI is not directly related to ICP balance.
D. BP, brain tissue, and ventricles of the brain: The ventricles are involved in cerebrospinal fluid production but are not one of the primary components of ICP balance as a whole.

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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

For the patient after a craniotomy, which intracranial pressure (ICP) reading would the nurse report immediately to the healthcare provider?

Correct Answer is C

Explanation

When explaining normal intracranial pressure (ICP) balance to the patient's family, which three components would the nurse include?

Correct Answer is B

Explanation

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