Which one of the following indicates an increase in intracranial pressure following head injury, Except?

Appeared in: SCTIMST Staff Nurse - 2015 (Set-A)

Explanation

Decreasing temperature (hypothermia) is not a characteristic sign of rising intracranial pressure.
In contrast, hyperthermia (fever) is a more common and unfavorable sign in patients with head injuries, as it can indicate brainstem damage and increases the brain's metabolic demands.
The body's compensatory response to increased ICP, known as Cushing's triad, involves changes in blood pressure and pulse rate, but not a decrease in temperature.

Option B: A decreased pulse rate (bradycardia) is a classic component of Cushing's triad, a late sign of significantly increased ICP.
Option C: Increasing blood pressure, specifically a rise in systolic pressure, is a key feature of Cushing's triad as the body attempts to maintain cerebral perfusion.
Option D: A widening pulse pressure (the difference between systolic and diastolic BP) is a direct result of the sharp increase in systolic pressure seen in Cushing's triad.

Clinical Relevance

Nursing practice connection: Knowing Signs and symptoms of increased intracranial pressure (ICP) helps nurses interpret findings accurately and avoid errors in routine assessment, medication administration, and patient teaching.
Recognizing Cushing's triad is a critical nursing skill, as it indicates a neurological emergency requiring immediate intervention to prevent brain herniation and death.
Nurses must perform frequent neurological assessments, including vital signs and Glasgow Coma Scale (GCS), to detect subtle changes that may precede the full development of Cushing's triad.
Nursing interventions for suspected increased ICP include elevating the head of the bed to 30 degrees, maintaining the neck in a neutral position, managing fever, and minimizing environmental stimuli.

How to Approach the Question

First, identify the core concept: signs of increased intracranial pressure (ICP).
Note the keyword 'Except'. This means you are looking for the option that is NOT a sign of increased ICP.
Recall or look up the classic signs of increased ICP, which are known as Cushing's triad.
Evaluate each option against the components of Cushing's triad: increasing blood pressure, decreasing pulse rate, and irregular respirations. Also consider related signs like widening pulse pressure.
The option that does not fit this pattern is the correct answer. In this case, decreasing temperature is inconsistent with the typical response to severe brain injury.

Concept Tested & Keywords

Concept Tested: Signs and symptoms of increased intracranial pressure (ICP)
Stem keywords: intracranial pressure, head injury
Lead-in keywords: Except
Negative lead-in flag: The question asks for the sign that is NOT indicative of increased ICP.

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E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 89-91, 30-32

Practise the full SCTIMST Staff Nurse - 2015 (Set-A)

Attempt every question from this paper in a timed mock, then review the full solution for each one.