Difficulty: Medium
Average Score: 78%
Simulated
Passage / Scenario
A nurse is caring for a client who experienced a traumatic brain injury 72 hours ago.Which finding should the nurse identify as a potential indication of increased intracranial pressure?
Correct answer
D
Rationale
The correct answer is D, "All of the above." Increasingly severe headache is a common symptom of increased intracranial pressure due to brain tissue compression. Bradycardia and hypertension can occur as a result of increased intracranial pressure affecting the autonomic nervous system. Dilated, non-reactive pupils may indicate brainstem compression. Therefore, all of these findings are potential indications of increased intracranial pressure. Choices A, B, and C all individually point towards different manifestations of increased intracranial pressure, making them incorrect if considered in isolation.