Question

The nurse suspects a patient has increased intracranial pressure. Which assessment findings may indicate this condition? Select all that apply.

-The patient is alert and oriented.

-The patient is experiencing hemiplegia.

-The patient has unilateral pupil dilation.

-The patient has a regular respiratory rate of 14.

-The patient is vomiting without preceding nausea.

Answer 1

Increased intracranial pressure can be indicated by (2) hemiplegia, (3) unilateral pupil dilation, and (5)vomiting without preceding nausea, as these signs suggest neurological impairment that could be due to brain pressure. Symptoms like alertness and a regular respiratory rate are less likely to be associated with increased intracranial pressure.

Step-by-step explanation:

The assessment findings that may indicate increased intracranial pressure in a patient are varied. Not all symptoms may be present, and each case can be different.

However, certain signs are particularly indicative of increased intracranial pressure.

• The patient experiencing hemiplegia: Hemiplegia, or paralysis on one side of the body, can be a result of brain injury or stroke which may also cause increased intracranial pressure.
  
  
• The patient has unilateral pupil dilation: Unequal pupils or anisocoria can suggest pressure on the cranial nerves, specifically the third cranial nerve, which may be a sign of increased intracranial pressure.
  
  
• The patient is vomiting without preceding nausea: Vomiting without nausea can be a non-specific sign, but when related to increased intracranial pressure, it reflects irritation or pressure on the brain areas responsible for vomiting reflexes.

An alert and oriented patient would not necessarily indicate increased intracranial pressure as this suggests normal brain function. Similarly, a regular respiratory rate does not typically imply increased intracranial pressure as dangerous levels of pressure usually alter the respiratory patterns.