Question

A nurse is caring for a client who has a closed head injury and has an intravascular catheter placed. Which of the following findings indicate that the client is experiencing increased intracranial pressure (ICP)?

a) Decreased blood pressure
b) Increased heart rate
c) Clear cerebrospinal fluid drainage
d) Responsive to verbal stimuli

Answer 1

Increased blood pressure is the indication of increased intracranial pressure (ICP) in a client with a closed head injury, disturbing the normal CSF pressure that provides flotation to the brain.

Step-by-step explanation:

The question posed relates to the clinical signs indicative of increased intracranial pressure (ICP) in a client with a closed head injury. The option that correctly indicates increased ICP among the provided choices is increased blood pressure. Elevated ICP can lead to constricted cerebral blood flow and can alter the dynamics of intracranial blood and cerebrospinal fluid (CSF). Normally, CSF pressure ranges from 5 to 12 mm Hg, providing flotation to the brain. When ICP increases, this equilibrium is disturbed, leading to symptoms such as headache, vomiting, altered consciousness, and hypertension due to the body's attempt at maintaining cerebral perfusion. Clear cerebrospinal fluid drainage and responsiveness to verbal stimuli are not direct indicators of increased ICP. Conversely, decreased blood pressure can be associated with shock or other systemic issues.