The nurse is caring for a client with a closed head injury. Which of the following symptoms indicates that the client's condition is worsening? Select all that apply.

 

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Correct

- Rising systolic pressure and decreasing diastolic pressure

- Bradycardia

- Abnormally low temperature

- Negative Babinski reflex

- Spontaneous eye opening

Rationale

-"Rising systolic pressure and decreasing diastolic pressure" and "Bradycardia" are correct. In a closed head injury, there is a high risk of increased intracranial pressure (ICP). The nurse should monitor for signs of increased ICP, which include an altered level of consciousness, widening pulse pressure, bradycardia, fever, vomiting and pupil changes.

-"Abnormally low temperature" is incorrect because the patient with increasing ICP will have an increased temperature.

-"Negative Babinski reflex" is incorrect because the patient with increasing ICP will have a positive Babinski reflex.

-"Spontaneous eye opening" is incorrect because spontaneous eye opening is a normal neurologic finding in which the patient opens their eyes whenever they choose. The patient with increasing ICP will develop an altered level of consciousness, which can affect eye opening as well.

References:
Silvestri, L. A. (2017). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier

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