Question

The nurse is monitoring a patient for increased ICP following a head injury. Which of the following manifestations indicate an increased ICP?

1) fever
2) oriented to name only
3) narrowing pulse pressure
4) dilated right pupil > left pupil
5) decorticate posturing to painful stimulus

Answer 1

Manifestations indicating increased ICP include a dilated right pupil greater than the left and decorticate posturing to painful stimuli. The correct option is 4.

Step-by-step explanation:

The manifestations that indicate increased intracranial pressure (ICP) following a head injury include: 4) dilated right pupil > left pupil and 5) decorticate posturing to painful stimulus. A fever can be associated with infection or inflammation such as in meningitis but is not specific to increased ICP.

Being oriented to name only is indicative of altered mental status which can be due to various causes, including increased ICP, but is not a definitive sign. Narrowing pulse pressure is not typically associated with increased ICP; instead, widening pulse pressure might be observed. Lastly, decorticate posturing indicates severe brain damage and is often associated with conditions that elevate ICP.