NCLEX-PN

Category - Physiological Adaptation

A client is admitted to the facility after sustaining a traumatic head injury. The nurse monitoring the client notes that the systolic blood pressure of the client is increasing as the diastolic blood pressure gradually decreases. The nurse informs the physician about the findings, drawing a conclusion that the client is experiencing:
  1. Spinal shock
  2. Increased intracranial pressure
  3. Autonomic dysreflexia
  4. Seizures
Explanation
Answer: B - An increasing intracranial pressure is mainly manifested by an increasing systolic blood pressure with gradual decrease of the diastolic blood pressure. This results in widening of the pulse pressure. The other options are not correct.
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