Question

Which clients' vital signs indicating increased intracranial pressure (ICP) should the nurse report to the health care provider?

a. P 70, BP 120/60 mmhg; P 100, BP 90/60 mmhg; rapid respirations
b. P 110, BP 130/ \70 mmhg; P 100, BP 110/70 mmhg; shallow respirations
c. P 130, BP 190/90 mmhg; P 136, BP 200/100 mmhg; Kussmaul respirations
d. P 55, BP 160/70 mmhg; P 50, BP 194/70 mmhg; irregular respirations

Answer 1

The nurse should report clients with vital signs indicating increased intracranial pressure (ICP) to the health care provider.

Step-by-step explanation:

The nurse should report clients with vital signs indicating increased intracranial pressure (ICP) to the health care provider. In option C, the vital signs P 130, BP 190/90 mmhg; P 136, BP 200/100 mmhg; and Kussmaul respirations are indicative of increased ICP. A normal blood pressure is between 90/60 and 120/80 mm Hg, so the elevated blood pressure in this option suggests increased ICP. Kussmaul respirations are deep and rapid, and they occur in response to the body's attempt to compensate for metabolic acidosis, which can be caused by cerebral edema resulting from increased ICP.