Practice Question
Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?
Answer Choices:
Correct Answer:
0800: Heart rate 55 beats/minute, blood pressure 160/70 mm Hg; 1200: heart rate 50 beats/minute, blood pressure 194/70 mm Hg, irregular respirations.
Rationale:
💎 Cushing’s Triad — bradycardia, widened pulse pressure (elevated systolic BP with low diastolic), and irregular respirations — is a classic sign of increased intracranial pressure (ICP).
💎 The combination of decreasing heart rate and increasing blood pressure reflects brainstem compression due to elevated ICP.
💎 Irregular respirations (Cheyne-Stokes or ataxic breathing) occur as ICP affects the medulla’s respiratory center.
💎 These changes signify a neurologic emergency, requiring immediate intervention to prevent brain herniation.
💎 The nurse should notify the healthcare provider at once, prepare for ICP management (e.g., hyperventilation, mannitol, positioning), and monitor for further deterioration.
Want to practice more questions like this?
This question is from HESI EXIT which contains 102 questions.
More Questions from This Exam
A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?
Answer Choices:
The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.)
Answer Choices:
A client who had bariatric surgery 2 months ago is admitted because of vomiting and inability to tolerate food and liquids. The client is pain free. Which intervention should the nurse include in the client's plan of care?
Answer Choices:
The client is a 24-year-old female who fell while horseback riding.
Answer Choices:
The client is a 24-year-old female who fell while horseback riding.
Answer Choices:
Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI-Exit Exam(s)
- Domain: HESI Exit Exam(s)~2024
- Answer Choices: 4