A nurse is caring for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

Choice A Reason:
Hypotension is not typically a direct manifestation of increased intracranial pressure (ICP). In fact, increased ICP often leads to hypertension as part of Cushing's triad, which includes hypertension, bradycardia, and irregular respiration. Hypotension may indicate other issues such as shock or blood loss but is not a primary indicator of increased ICP.

Choice B Reason:
Tachypnea, or rapid breathing, is not a primary sign of increased ICP. While respiratory changes can occur with increased ICP, they are more likely to present as irregular breathing patterns rather than simply an increased rate. Tachypnea might be seen in conditions like anxiety, pain, or respiratory distress but is not a hallmark of increased ICP.

Choice C Reason:
Bilateral weakness of extremities can occur with increased ICP, especially if there is significant brain swelling or herniation affecting motor pathways. However, it is not the most immediate or specific sign. Other neurological deficits can also cause bilateral weakness, so it is not solely indicative of increased ICP.

Choice D Reason:
Decreased level of consciousness is a critical and primary sign of increased ICP. As pressure within the skull rises, it can compress brain structures and impair function, leading to altered mental status ranging from confusion to coma. Monitoring the level of consciousness is essential in assessing and managing patients with potential increased ICP.

Choice A Reason:
Narrowing pulse pressure is not typically associated with contusions from a motor-vehicle crash. It is more commonly seen in conditions like cardiac tamponade or severe blood loss. While it can indicate a serious condition, it is not a direct result of a contusion.

Choice B Reason:
Drainage of clear fluid from the ears, known as otorrhea, can indicate a basilar skull fracture rather than a simple contusion. This finding suggests cerebrospinal fluid leakage, which is a serious complication requiring immediate medical attention.

Choice C Reason:
Periods of unconsciousness and/or confusion are expected findings in clients with contusions, especially if the brain is involved. These symptoms indicate a concussion or more severe brain injury, which can result from the impact of a motor-vehicle crash.

Choice D Reason:
Extensive bruising in the mastoid area, known as Battle's sign, is indicative of a basilar skull fracture rather than a contusion. This type of bruising appears behind the ear and is a sign of a more severe head injury.