Neurological Question #1

Question

A client injured in a motor vehicle accident is transferred to the intensive care unit with a diagnosis of head trauma. The emergency room nurse reports the client has increased intracranial pressure. Which assessment findings are the most important for the nurse to monitor? (Select all that apply)

Answers

  1. Urine output
    • Rationale:
  2. Rate of respirations
    • Rationale:
  3. Cerebral perfusion pressure
    • Rationale:
  4. Systolic blood pressure
    • Rationale:

Overview

Explanation

The systolic plus diastolic blood pressures are important and necessary in order to monitor mean arterial pressure (MAP). The MAP is necessary to assess since it reflects pressure required for brain perfusion with each cardiac cycle.The intracranial pressure (ICP) and MAP will provide analysis of cerebral perfusion pressure. While urine output, respiratory rate are important, the question is focused on critical indicators associated with head trauma.

Learning Outcomes

Test Taking Tip

Video Rationale