Difficulty: Medium
Average Score: 77%
Simulated
A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
Correct answer
C
Rationale
Altered level of consciousness is the earliest and most sensitive sign of increased ICP, detectable via the Glasgow Coma Scale. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs indicating severe brainstem involvement.