A client with a head injury has an arterial blood pressure of 104/56 mmHg and an intracranial pressure of 13 mmHg. Which action by the nurse is appropriate?

Document and continue to monitor the parameters.

Decrease the client's IV infusion rate.

Check the client's pupillary response to light.

Notify the health care provider about the assessments.

Answer and Explanation

The Correct Answer is A

A. Document and continue to monitor the parameters: The client’s MAP and ICP values are within acceptable limits. MAP is 72 mmHg, and CPP (MAP − ICP = 72 − 13 = 59 mmHg) is near the lower threshold of adequate cerebral perfusion. Continuous monitoring is appropriate to detect any changes.

B. Decrease the client's IV infusion rate: Reducing IV fluids is unnecessary because blood pressure and cerebral perfusion are currently adequate. Doing so could lower MAP and risk inadequate cerebral perfusion.

C. Check the client's pupillary response to light: Pupillary assessment is important, but it is a routine neurological check. In the absence of new changes in mental status or vital signs, it is not the highest-priority action compared to ongoing monitoring of current parameters.

D. Notify the health care provider about the assessments: There is no urgent abnormality in the blood pressure or ICP at this time. Immediate notification is not required unless trends show deterioration.

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Correct Answer is A

Explanation

A. quality of respirations and presence of central pulses: Airway, breathing, and circulation are the top priorities in trauma care. Ensuring adequate oxygenation and perfusion takes precedence over other injuries, as compromise in these areas can quickly become life-threatening.

B. abdominal contusions and other wounds: While important to assess for internal bleeding or organ injury, these are secondary to securing airway, breathing, and circulation in the initial assessment.

C. level of consciousness and pupil size: Neurological assessment is essential but comes after ensuring the client’s vital functions are stabilized. Changes in mental status may follow hypotension or hypoxia, so primary stabilization must occur first.

D. pain and deformities in the lower extremities: Pain management and extremity assessment are important but are lower priority compared with life-threatening issues such as impaired breathing or absent central pulses.

A. pH 7.50; PaCO2 28 mmHg: PaO2 100 mmHg: HCO3 24 mEq/L B. pH 7.34; PaCO2 60 mmHg: PaO2 68 mmHg; HCO3 30 mEq/L C. pH 7.50; PaCO2 28 mmHg: PaO2 58 mmHg: HCO3 24 mEq/L D. pH 7.34; PaCO2 25 mmHg: PaO2 80 mmHg: HCO3 19 mEq/L

Correct Answer is C

Explanation

A. pH 7.50; PaCO2 28 mmHg; PaO2 100 mmHg; HCO3 24 mEq/L: While respiratory alkalosis is present, the PaO2 is normal, which is not consistent with early ARDS. Early ARDS typically shows hypoxemia with low PaO2 despite supplemental oxygen, reflecting impaired gas exchange.

B. pH 7.34; PaCO2 60 mmHg; PaO2 68 mmHg; HCO3 30 mEq/L: Elevated PaCO2 and normal pH with mild hypoxemia suggest respiratory acidosis, which is more characteristic of late or severe ventilatory failure, not early ARDS. Early ARDS usually presents with hypoxemia and compensatory hyperventilation.

C. pH 7.50; PaCO2 28 mmHg; PaO2 58 mmHg; HCO3 24 mEq/L: This ABG demonstrates hypoxemia (PaO2 < 60 mmHg) and respiratory alkalosis due to hyperventilation, which is typical in the early stages of ARDS as the patient attempts to compensate for impaired oxygenation. This pattern aligns with early ARDS pathophysiology.

D. pH 7.34; PaCO2 25 mmHg; PaO2 80 mmHg; HCO3 19 mEq/L: While PaCO2 is low, the PaO2 is normal, indicating adequate oxygenation. Early ARDS usually presents with significant hypoxemia despite initial compensation, so this ABG does not match early ARDS.

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