Neurological Question #2

Question

The nurse is caring for a client with increased intracranial pressure (ICP). Which assessment finding would have the most priority?

Answers

  1. Tachycardia
    • Rationale:
  2. Hypothermia
    • Rationale:
  3. Unequal pupil size
    • Rationale:
  4. Decreasing blood pressure
    • Rationale:

Overview

Explanation

Pupil size may be affected by increased pressure which affects the third cranial nerve which is one reason for frequent monitoring of pupillary size and response. When ICP increases it affects the hypothalamus and temperature regulation, thus increasing temperature. When ICP increases, it causes pressure on the vagus nerve, thus causing bradycardia not tachycardia. ICP increases cause increase in blood pressure not decreasing blood pressure.

Learning Outcomes

Test Taking Tip

Video Rationale