When obtaining the vital signs of a client with multiple traumatic injuries, the nurse detects bradycardia, bradypnea, and systolic hypertension.
Nurse Ashley must notify the physician immediately because these findings may reflect which complication?
a- Shock
b- Encephalitis
c- Increased intracranial pressure (ICP)
d- Status epilepticus
Answer C.
Decreased heart and respiratory rates and increased systolic blood pressure reflect Cushing’s triad, which may develop when ICP increases.
Shock typically causes tachycardia, tachypnea, and hypotension.
In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate.
If the client doesn’t maintain adequate hydration, hypotension may occur.
Status epilepticus causes unceasing seizures, not changes in vital signs.
Nurse Ashley must notify the physician immediately because these findings may reflect which complication?
a- Shock
b- Encephalitis
c- Increased intracranial pressure (ICP)
d- Status epilepticus
Answer C.
Decreased heart and respiratory rates and increased systolic blood pressure reflect Cushing’s triad, which may develop when ICP increases.
Shock typically causes tachycardia, tachypnea, and hypotension.
In encephalitis, the temperature rises and the heart and respiratory rates may increase from the effects of fever on the metabolic rate.
If the client doesn’t maintain adequate hydration, hypotension may occur.
Status epilepticus causes unceasing seizures, not changes in vital signs.
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Physiological Integrity