When caring for a patient with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

Hypertension and narrowing pulse pressure.

Elevated systolic blood pressure and bradycardia

Hypotension and tachycardia.

Hypotension and bradycardia.

Answer and Explanation

The Correct Answer is B

A. Hypertension and narrowing pulse pressure: Increased intracranial pressure leads to a widening pulse pressure rather than a narrowing one. As ICP rises, systolic pressure increases while diastolic pressure may remain stable or decrease, producing a widened pulse pressure. Narrow pulse pressure is not characteristic of late ICP elevation.

B. Elevated systolic blood pressure and bradycardia: These are classic components of Cushing’s triad, a late and ominous sign of significantly increased ICP. Rising ICP decreases cerebral perfusion, triggering sympathetic-mediated hypertension to maintain blood flow. The resulting baroreceptor response causes reflex bradycardia, indicating brainstem involvement and impending herniation.

C. Hypotension and tachycardia: Hypotension and tachycardia are more consistent with hypovolemia or shock rather than increased ICP. In elevated ICP, the body attempts to preserve cerebral perfusion by increasing systemic blood pressure, not lowering it.

D. Hypotension and bradycardia: This combination does not reflect the compensatory physiologic response to increased ICP. Late ICP elevation is associated with systemic hypertension, not hypotension, as the body attempts to overcome reduced cerebral perfusion pressure.

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Correct Answer is C

Explanation

A. Apply dressings to burned areas: Wound care is important to reduce infection risk and protect damaged tissue, but in electrical burns, internal injuries may be more severe than external findings. Covering the wounds does not address immediate life-threatening complications such as cardiac dysrhythmias.

B. Assess for pain at contact points: Pain assessment is a routine component of burn care; however, electrical injuries may cause deep tissue damage with minimal external pain initially. Life-threatening cardiac complications take precedence over pain evaluation in the primary survey.

C. Place on a cardiac monitor: Electrical burns can disrupt myocardial conduction pathways, predisposing the patient to lethal dysrhythmias such as ventricular fibrillation. Continuous cardiac monitoring allows early detection and rapid intervention for arrhythmias, which are a leading cause of mortality in electrical injuries. Immediate monitoring is critical upon arrival.

D. Start two large bore IVs: Establishing large-bore IV access is essential for fluid resuscitation and medication administration. However, dysrhythmias can occur immediately after electrical exposure, making cardiac monitoring the first priority to detect and treat potentially fatal conduction abnormalities.

A. Creatinine clearance B. Phosphate level C. Blood pressure D. Neurologic status

Correct Answer is B

Explanation

A. Creatinine clearance: Creatinine clearance reflects glomerular filtration rate and overall kidney function but does not directly indicate the effectiveness of calcium carbonate therapy. Calcium carbonate is prescribed as a phosphate binder, and its efficacy is assessed by changes in serum phosphate rather than kidney filtration rate.

B. Phosphate level: Calcium carbonate binds dietary phosphate in the gastrointestinal tract, reducing absorption and helping to manage hyperphosphatemia, which is common in CKD. Monitoring serum phosphate levels allows the nurse to determine whether the medication is effectively lowering phosphate and preventing complications.

C. Blood pressure: Blood pressure management is important in CKD, but calcium carbonate does not directly influence blood pressure. While hypertension can exacerbate kidney disease, changes in blood pressure are not a reliable indicator of calcium carbonate’s therapeutic effect.

D. Neurologic status: Neurologic changes can occur in severe electrolyte imbalances or uremia, but they are not specific indicators of calcium carbonate effectiveness. Monitoring neurologic status is important for overall patient safety but does not directly reflect phosphate control achieved by the medication.

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When caring for a patient with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?

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