NCLEX-RNPhysiological AdaptationMedium
A nurse is caring for a client with a traumatic brain injury and intracranial pressure monitoring. The nurse notes a blood pressure of 178/60 mm Hg, heart rate of 48/min, and irregular respirations. Which action should the nurse take first?
- ANotify the healthcare provider immediately of the findings
- BElevate the head of the bed to 90 degrees and reassess in 30 minutes
- CDocument the findings as an expected postoperative change
- DAdminister the prescribed PRN antihypertensive medication
Show answer & explanationAnswer & explanation
Correct answer: A. Notify the healthcare provider immediately of the findings
Widened pulse pressure, bradycardia, and irregular respirations constitute Cushing's triad, a late and ominous sign of rising intracranial pressure and impending brain herniation. The nurse must notify the provider immediately for emergent intervention (e.g., osmotic diuretics, hyperventilation, or surgical decompression) rather than delaying with routine measures.
Why the other options are wrong
- B. Delaying notification while waiting to reassess risks herniation and death.
- C. This is not an expected finding; it indicates a critical deterioration.
- D. Lowering blood pressure could worsen cerebral perfusion in the setting of rising ICP.
Cushing's Triad
A late sign of increased intracranial pressure consisting of widened pulse pressure/hypertension, bradycardia, and irregular respirations, indicating impending brain herniation.
- Reflects the body's attempt to maintain cerebral perfusion against rising ICP
- A neurologic emergency requiring immediate provider notification
- Untreated progresses to herniation and death
Memory trick: High pressure, slow heart, weird breath = brain in death