Question

The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply.

A. systolic blood pressure
B. urine output
C. breath sounds
D. cerebral perfusion pressure
E. level of pain

Answer 1

Critical indicators to monitor in a client with increased ICP are systolic blood pressure, urine output, breath sounds, cerebral perfusion pressure, and the level of pain. These metrics are essential for evaluating ICP status and any associated complications.

Step-by-step explanation:

When monitoring a client with increased intracranial pressure (ICP), the most critical indicators for a nurse to monitor include systolic blood pressure, urine output, breath sounds, cerebral perfusion pressure (CPP), and the level of pain. These are crucial variables that can impact and reflect the status of a patient with ICP. Systolic blood pressure is part of determining CPP, which shows the pressure needed for oxygen and nutrients to penetrate the brain. Urine output can reflect the autonomic nervous system response or can be affected by medications used in the management of ICP. Breath sounds are monitored because neurogenic pulmonary edema can be a complication of increased ICP. Monitoring pain levels is important for assessing comfort and potential for increased ICP, as pain can lead to sympathetic nervous system activation which potentially elevates ICP further.