The nurse is assessing vital signs of a patient with head injury. Which of the following finding indicates increased intracranial pressure?

Appeared in: HPSSSB Staff Nurse - 2016

Explanation

Bradypnea, or an abnormally slow respiratory rate, is a classic component of Cushing's Triad.
Cushing's Triad is a physiological response to increased intracranial pressure that leads to brainstem compression.
The triad consists of three key vital sign changes: hypertension (with a widened pulse pressure), bradycardia (slow heart rate), and irregular respirations (including bradypnea).
The presence of these signs indicates a neurological emergency requiring immediate intervention.

Option A: Increased ICP typically causes bradycardia (a slow heart rate), not tachycardia.
Option C: Increased ICP leads to hypertension (increased blood pressure), not hypotension.
Option D: Pressure on the hypothalamus from increased ICP can disrupt temperature regulation, but it typically causes hyperthermia (increased body temperature), not hypothermia.

Clinical Relevance

Nursing practice connection: Use the key finding related to Signs of Increased Intracranial Pressure (ICP) and Cushing's Triad to guide bedside assessment, documentation, and the next nursing action.
Recognizing Cushing's Triad is a critical nursing skill, as it signifies a late and life-threatening increase in ICP that requires immediate medical and surgical intervention to prevent brain herniation and death.
Nursing priorities for a patient with suspected increased ICP include frequent neurological assessments (including GCS and vital signs), maintaining head and neck alignment, elevating the head of the bed, and minimizing environmental stimuli.
What if? If a patient with a head injury presented with hypotension and tachycardia instead, the priority would shift to suspecting and managing hypovolemic shock from internal or external bleeding, as these are the classic signs of shock, not isolated increased ICP.

How to Approach the Question

First, identify the key concepts in the question: 'head injury' and 'increased intracranial pressure'.
Recall the classic vital sign changes associated with increased ICP. The mnemonic 'Cushing's Triad' is essential here.
Mentally list the three components of Cushing's Triad: 1. Hypertension (high BP), 2. Bradycardia (low heart rate), and 3. Bradypnea/Irregular Respirations (slow/abnormal breathing).
Systematically evaluate each option against the components of Cushing's Triad.
Tachycardia is the opposite of bradycardia. Decreased blood pressure is the opposite of hypertension. Decreased temperature is not part of the triad (hyperthermia is more common).
Identify that Bradypnea directly matches the respiratory component of the triad and select it as the correct answer.

Concept Tested & Keywords

Concept Tested: Signs of Increased Intracranial Pressure (ICP) and Cushing's Triad
Stem keywords: vital signs, head injury, increased intracranial pressure
Lead-in keywords: indicates
Clinical cues: The patient has a head injury, which is a primary risk factor for developing increased ICP.

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 p. 89-91

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