NCLEX-PN Review Question #2

A nurse is caring for a client with increased intracranial pressure (ICP). The nurse would monitor for which of the following trends in vital signs that would occur if ICP is rising?

1. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure
2. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure
3. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure
4. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure

Answer: 1

Rationale: A change in vital signs may be a late sign of increased ICP. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health/Neurological

Reference: Saunders Comprehensive Review for the NCLEX-PN Examination Edition 4 by Linda Silvestri

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