Question

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?

a. Document the BP and ICP in the patient's record.
b. Report the BP and ICP to the health care provider.
c. Elevate the head of the patient's bed to 60 degrees.
d. Continue to monitor the patient's vital signs and ICP.

Answer 1

The nurse should report the abnormal findings of the blood pressure (BP) and intracranial pressure (ICP) to the health care provider first. Immediate medical intervention may be necessary for a patient with a diffuse axonal injury.

Step-by-step explanation:

The nurse should take action b. Report the BP and ICP to the health care provider first. A systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg are both abnormal readings for a patient with a diffuse axonal injury. These readings indicate the need for immediate medical intervention to ensure the patient's safety and well-being. By reporting the BP and ICP to the health care provider, the nurse can facilitate appropriate interventions and further assessment of the patient's condition.