Today’s NCLEX-RN® question of the day focuses on a nurse recognizing a sign of increased intracranial pressure.
When caring for a client diagnosed with an intracranial tumor, which observation should the nurse recognize as a sign of increased intracranial pressure (ICP)?
A. Widened pulse pressure
B. Periorbital edema
C. Tachycardia
D. HallucinationsScroll down for the correct answer!
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The correct answer to today’s NCLEX-RN® Question is…
A. Widened pulse pressure
Rationale: Increased ICP is characterized by signs referred to as the Cushing’s Triad. One component of Cushing’s Triad is a widened pulse pressure which occurs due to increased systolic blood pressure. The other two components are bradycardia and bradypnea.
Main takeaway
Increased intracranial pressure (ICP) is characterized by signs referred to as the Cushing Triad. The components of Cushing’s Triad include bradycardia, bradypnea, and a widening pulse pressure which occurs due to increased systolic blood pressure. Other signs include papilledema, headache, blurred vision, vomiting, changes in behavior, weakness, lethargy, and loss of consciousness.
Incorrect answer explanations
B. Periorbital edema
Rationale: Periorbital edema is swelling around the eye socket caused by problems like infections, allergies, and hypothyroidism. Increased ICP is characterized by another ocular sign called papilledema, which is swelling of the optic disc from pressure on the optic nerve. Papilledema is diagnosed by ophthalmoscopy.
C. Tachycardia
Rationale: Increased ICP is characterized by signs referred to as the Cushing’s Triad. One component of the triad is bradycardia, not tachycardia.
D. Hallucinations
Rationale: Increased ICP does not typically result in hallucinations. More commonly, clients with increased ICP experience restlessness in the early stages which can progress to changes in behavior, lethargy, and loss of consciousness.
References
McCance, K.L., Huether, S.E., Brashers, V.L., & Rote, N.S. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Elsevier.
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