ATI n269 Med Surg Exam 1

Extract:

Question 1 of 5

When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min D. BP 172/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

Correct Answer: D

Rationale: BP 172/54 mm Hg, bradycardia (58 beats/min), and hypoventilation (10 breaths/min) suggest Cushing's triad, a critical sign of increased ICP requiring immediate reporting.

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ATI n269 Med Surg Exam 1 | Nurselytic

Nurselytic

ATI RN

ATI RN