Question

A nures in the critical care unit is completing an admission assessment of a client who has a gunshot wound to the head. Which of the following assessment findings are indicative of increased ICP? (Select all that apply.)

A.) Headache
B.) Dilated pupils
C.) Tachycardia
D.) Decorticate posturing
E.) Hypotension

Answer 1

A rapid assessment of neurological function is important in an emergency situation as it helps in determining the location and severity of the injury. Increased intracranial pressure (ICP) can be indicated by symptoms such as headache, dilated pupils, and tachycardia.

Step-by-step explanation:

When assessing a client with a gunshot wound to the head, a nurse in the critical care unit should be vigilant for signs of increased intracranial pressure (ICP). The following assessment findings are indicative of increased ICP:

• Headache: A headache can be a common symptom of increased ICP as the pressure builds up within the skull.
• Dilated pupils: Dilated pupils can occur due to pressure on the cranial nerves controlling the pupillary reflex.
• Tachycardia: Increased heart rate may be a compensatory response to the increased pressure in the brain.

Therefore, the correct options for this question are A) Headache, B) Dilated pupils, and C) Tachycardia.