43. Which respiratory change would a nurse see most often in a client with increased intracranial pressure?
43. Which respiratory change would a nurse see most often in a client with increased intracranial pressure?
. Nasal flaring and retractions.
. Slow, irregular respirations.
. Rapid, deep respirations.
. Paradoxical chest movements.
Test-Taking Tip
Eliminate Answer 3 as it is the opposite of what occurs (Answer 2). Eliminate Answers 1 and 4, because the conditions are not characteristic of increased ICP, but of pulmonary edema and chest trauma. Remember that the pressure in the brain will interfere with the regulatory center. Respiratory response will be irregular.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Assessment; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is incorrect because nasal flaring and retractions would be seen with pulmonary edema and left-sided heart failure. Answer 2 is correct because increased intracranial pressure (ICP) presses on the structures of the brain, causing irregularities such as Cheyne-Stokes respirations. Answer 3 is incorrect because slow, irregular breathing is more common. Hyperventilation may occur with pressure in the midbrain. Answer 4 is incorrect because paradoxical chest movements are characteristic of flail chest from chest trauma.