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A patient was involved in an MVA and suffered a traumatic brain injury (TBI). The nurse must monitor the patient's intracranial pressure (ICP). Which of the following would the nurse associate with an increased ICP?

Explanation

• A change in the level of consciousness is typically the first sign of increased ICP

• Increased ICP puts pressure on the brainstem. This affects the patient's motor function and is indicated by posturing, either decorticate or decerebrate. Decorticate posturing is a stiff body, bent arms, clenched fists, and legs straight.  Decerebrate posturing is a stiff body, arms and legs straight with toes pointing down, and head and neck arched backwards

• Increased BP, decreasing pulse, and altered respirations are called Cushing's triad. These are typically late signs that represent a loss of compensatory mechanisms and indicate a presentation of brainstem dysfunction

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