NursingPlex
    Sign In
    Hesi RN exit proctored examQuestion 88
    88 / 130
    Hesi RN exit proctored exam

    Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

    Explanation & Rationale

    A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP. B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting. C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP. D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.

    🔒 Submit your answer to reveal