The unit nurse is teaching a nursing student about increased intracranial pressure (ICP). The nurse knows the teaching was effective if the student nurse makes which statement?
“Altered level of consciousness is a late sign of increased ICP.”
“Elevated temperature is the earliest indication of increased ICP.”
“Late signs of increased ICP include narrowed pulse pressure and a lowered heart rate.”
“Late signs of increased ICP include increased systolic blood pressure and a widened pulse pressure.”
Number 4 is correct.
Rationale: Increased ICP includes increased systolic blood pressure and widened pulse pressure, along with a decreased heart rate. Altered level of consciousness is the earliest and most sensitive manifestation of increased ICP. The client may have an elevated temperature, but this is not the earliest sign. Narrowed pulse pressure is not present with increased ICP.
