Editing Medical-Surgical Nursing – RN Practice Questions (section)

==Question 9==
A patient with a traumatic brain injury has a blood pressure that has risen from 128/76 to 176/68 mm Hg, a heart rate that has fallen from 88 to 50 beats per minute, and irregular respirations. What is the nurse's interpretation and priority action?
# These are expected findings after head trauma; continue routine monitoring.
# This is Cushing triad indicating impending herniation; notify the provider immediately.
# The patient is developing hypovolemic shock; increase the intravenous fluid rate.
# The patient is having a vasovagal response; lower the head of the bed flat.

'''Answer:''' Option 2, this is Cushing triad indicating impending herniation; notify the provider immediately.

''Rationale:'' Rising systolic pressure with a widening pulse pressure, bradycardia, and irregular respirations form Cushing triad, a late and ominous sign of severely elevated intracranial pressure with impending brainstem herniation. Immediate escalation is required. Option 1 fails to rescue. Option 3 is incorrect, because hypovolemic shock produces hypotension with tachycardia, and additional fluid could worsen cerebral edema. Option 4 is wrong and harmful; lying flat further increases intracranial pressure, and the head of the bed should remain elevated about thirty degrees with the head midline.