A 28-year-old male patient has been brought into the emergency department after suffering a closed head injury from a fall. The patient is demonstrating signs of the Cushing reflex. Based on the nurse's understanding of this condition, the nurse knows to look for signs of:


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- severe hypertension with a widening pulse pressure.

- decorticate posturing and fixed pupils.

- slow, deep breathing followed by periods of apnea.

- no physical response to stimulation.


A patient with a head injury may demonstrate increased intracranial pressure and altered levels of consciousness. The symptoms of a head injury may progressively worsen during the initial period following the injury. Cushing's reflex is a late sign following a head injury; it is characterized by severe hypertension and a widening pulse pressure.

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