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An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
A. Has a sudden and severe increase in intracranial pressure
B. Is beginning to experience a dangerously high level of anxiety
C. Has sustained an internal injury in addition to the head injury
D. Is having intracranial bleeding
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Widening pulse pressure (high systolic and low diastolic) with compensatory slowing of pulse rate are late signs of increasing ICP. (B) Rising pulse rate and lowering blood pressure are indicative of hypovolemia due to hemorrhage. (C) High anxiety, in the absence of hemorrhage, would result in a high pulse rate and a high blood pressure. (D) Intracranial bleeding results in increased ICP. A change in level of consciousness is an early sign of increasing ICP, and vital sign changes are late signs of increasing ICP.
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Aalk - 2014-05-05 16:45:18
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