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 C
Explanation
A. A flat supine position is not recommended for patients with meningitis; they should be kept at a 30- degree angle to reduce ICP.
B. Restraining the patient is unnecessary unless there is an immediate risk of harm, and it can cause distress.
C. Reducing environmental stimuli helps minimize discomfort and risk of seizures, especially in meningitis, which causes hypersensitivity to light and sound.
D. Fluid intake should be monitored carefully. Excessive fluids may increase ICP in a patient with meningitis.
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.
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