ESTUDYR
NCLEX-RN Case Study: Increased Intracranial
Pressure (ICP)
Client Scenario
2000 Nurses' Notes:
A 42-year-old male is admitted to the Neuro-ICU following a motor vehicle accident. He
sustained a closed-head injury and a temporal bone fracture. On admission at 1800, he was
alert and oriented.
Current Assessment (2000):
Neuro: The client is now difficult to arouse. He is oriented to person only. His pupils
are 3 mm and equal, but the left pupil is sluggish to light.
Motor: He withdraws from painful stimuli, but his right-sided grip is noticeably
weaker than the left.
Vital Signs: BP 168/60, HR 52, RR 12 and irregular. Temp 99.1°F.
Item 1: Recognizing Cues (Highlighting)
Question: Click to highlight the findings that indicate the client is experiencing a worsening
of neurological status.
Findings: 42-year-old male; difficult to arouse; oriented to person only; left pupil is
sluggish; right-sided grip is noticeably weaker; BP 168/60; HR 52; RR 12 and irregular.
Rationale: The earliest sign of increased ICP is a change in Level of Consciousness (LOC),
such as becoming difficult to arouse or confused. Sluggish pupils and unilateral weakness
indicate focal pressure on the brain. The combination of widened pulse pressure (168/60),
bradycardia (HR 52), and irregular respirations is known as Cushing's Triad, a late sign of
brainstem compression.
NCLEX-RN Case Study: Increased Intracranial
Pressure (ICP)
Client Scenario
2000 Nurses' Notes:
A 42-year-old male is admitted to the Neuro-ICU following a motor vehicle accident. He
sustained a closed-head injury and a temporal bone fracture. On admission at 1800, he was
alert and oriented.
Current Assessment (2000):
Neuro: The client is now difficult to arouse. He is oriented to person only. His pupils
are 3 mm and equal, but the left pupil is sluggish to light.
Motor: He withdraws from painful stimuli, but his right-sided grip is noticeably
weaker than the left.
Vital Signs: BP 168/60, HR 52, RR 12 and irregular. Temp 99.1°F.
Item 1: Recognizing Cues (Highlighting)
Question: Click to highlight the findings that indicate the client is experiencing a worsening
of neurological status.
Findings: 42-year-old male; difficult to arouse; oriented to person only; left pupil is
sluggish; right-sided grip is noticeably weaker; BP 168/60; HR 52; RR 12 and irregular.
Rationale: The earliest sign of increased ICP is a change in Level of Consciousness (LOC),
such as becoming difficult to arouse or confused. Sluggish pupils and unilateral weakness
indicate focal pressure on the brain. The combination of widened pulse pressure (168/60),
bradycardia (HR 52), and irregular respirations is known as Cushing's Triad, a late sign of
brainstem compression.
