Examkin

Question

Difficulty: MediumPhysiological Adaptation

Following a motor vehicle collision, a young adult client is admitted to the neurosurgical unit with a traumatic brain injury. The latest assessment reveals a blood pressure of 172/68 mm Hg and a heart rate of 52 beats per minute. Previous vital signs were a blood pressure of 130/82 mm Hg and a heart rate of 88 beats per minute. What is the most appropriate initial action for the nurse to perform?

  1. A
    Place the client flat and raise their legs above heart level.
  2. B
    Perform a detailed cranial nerve assessment to document neurological deficits.
  3. Elevate the head of the client's bed to 30 degrees.Answer
  4. D
    Prepare to administer a rapid intravenous infusion of isotonic crystalloids.

Answer

The most appropriate initial action is to elevate the head of the client's bed to 30 degrees.
The client's vital signs demonstrate a significantly widening pulse pressure and new-onset bradycardia. In a client with a traumatic brain injury, these are classic components of Cushing's triad, which indicates a dangerous physiological adaptation to an increase in intracranial pressure (ICP). Elevating the head of the bed to 30 degrees is the priority initial action because it promotes venous return from the brain, helping to reduce ICP.

Step-by-Step Solution

1
Analyze the vital sign changes over time.
The systolic blood pressure increased from 130 to 172 mm Hg (creating a significantly widening pulse pressure), and the heart rate decreased from 88 to 52 beats per minute.
Recognizing these specific trends is crucial for identifying Cushing's triad, a classic physiological response to increased intracranial pressure (ICP).
2
Determine the immediate clinical priority.
The priority is to implement measures that reduce intracranial pressure and maintain adequate cerebral perfusion.
Unrelieved increased ICP can rapidly lead to fatal brain herniation.
3
Select the most appropriate initial nursing intervention.
Elevating the head of the bed to 30 degrees is selected.
This specific position promotes jugular venous outflow by gravity, thereby lowering intracranial pressure effectively without causing harm.

Key Concept

Cushing's Triad and Management of Increased Intracranial Pressure
Estimated Time:1m 0s
Rate this question

Topics

Physiological Adaptation

More questions from this topic