Vital signs on a brain-injured client 1 hour ago were T 98.8° F, P 76, BP 124/72 . When the nurse takes a current set of vital signs that are T 98.4° F, P 56, BP 160/54, the nurse should
A) administer prn pain medications.
B) check the client's blood glucose level.
C) lower the head of the bed.
D) prepare to administer mannitol.

Question

Quizplus · Accepted Answer

Cushing's triad, or increased systolic blood pressure with widened pulse pressure and bradycardia, is a late response and indicates severe increased ICP with the failure of autoregulation. Treatment of increased ICP includes mannitol, an osmotic diuretic. There is no indication that the client needs pain medication or is hypoglycemic. Generally, the head of the bed in clients with increased intracranial pressure is elevated.

Vital Signs on a Brain-Injured Client 1 Hour Ago Were