Ati nur211 mobility exam
Ati nur211 mobility exam ( 29 Questions)
A nurse is looking after a client with a traumatic brain injury. Which signs of increased intracranial pressure should the nurse monitor for?
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.
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.
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.
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:
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.