Neurological checks: Time | 1000 | 1200 | 1400 | 1600; GCS | 14 | 13 | 11 | 9; Right pupil | 3 mm brisk | 3 mm brisk | 4 mm sluggish | 5 mm sluggish; Left pupil | 3 mm brisk | 3 mm brisk | 3 mm brisk | 3 mm brisk; Left hand grip | Strong | Strong | Weak | Weak Vital signs: Time | 1000 | 1600; BP (mm Hg) | 128/76 | 168/62; HR (/min) | 88 | 56; RR (/min) | 16 | 10, irregular; Temp (°C) | 37.0 | 37.2 A client is 6 hours post admission for a closed head injury. Which findings in the client record indicate that intracranial pressure is rising? Select all that apply.

Fall in Glasgow Coma Scale score from 14 to 9

Widening pulse pressure with bradycardia and irregular breathing

Right pupil enlarging and becoming sluggish

Initial blood pressure of 128/76 mm Hg

NCLEX-RN practice › Physiological Adaptation

NCLEX question: signs of rising intracranial pressure (SATA)

Physiological Adaptation · Select all that apply · Clinical judgment step: Recognize cues

Client record

Neurological checks

Time	1000	1200	1400	1600
GCS	14	13	11	9
Right pupil	3 mm brisk	3 mm brisk	4 mm sluggish	5 mm sluggish
Left pupil	3 mm brisk	3 mm brisk	3 mm brisk	3 mm brisk
Left hand grip	Strong	Strong	Weak	Weak

Vital signs

Time	1000	1600
BP (mm Hg)	128/76	168/62
HR (/min)	88	56
RR (/min)	16	10, irregular
Temp (°C)	37.0	37.2

A client is 6 hours post admission for a closed head injury. Which findings in the client record indicate that intracranial pressure is rising? Select all that apply.

A. Fall in Glasgow Coma Scale score from 14 to 9
B. Left pupil 3 mm and brisk
C. Initial blood pressure of 128/76 mm Hg
D. New weakness of the left hand
E. Widening pulse pressure with bradycardia and irregular breathing
F. Temperature of 37.2 °C
G. Right pupil enlarging and becoming sluggish

Show the answer and rationales

Answer: A, D, E, G

Declining GCS, an ipsilateral dilating pupil, contralateral weakness and Cushing's triad together show rising ICP with impending herniation. The provider must be notified immediately.

A. Correct. A drop of 2 or more points is a significant decline in consciousness, the earliest sign of rising ICP.
B. Incorrect. The unchanged left pupil is a normal finding.
C. Incorrect. The baseline blood pressure is normal; it is the change over time that matters.
D. Correct. Contralateral motor weakness reflects pressure on the motor pathways of the opposite hemisphere.
E. Correct. Hypertension with a widened pulse pressure, bradycardia and irregular respirations is Cushing's triad, a late sign of herniation.
F. Incorrect. A temperature of 37.2 °C is within normal limits and does not indicate rising ICP.
G. Correct. A dilating, sluggish pupil on the side of the lesion signals compression of cranial nerve III from herniation.

Scoring: select all that apply items on the Next Generation NCLEX use plus/minus scoring. You gain a point for each correct option you choose and lose a point for each incorrect one, with a minimum of zero. This item is worth 4 points.

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NCLEX question: signs of rising intracranial pressure (SATA)

Neurological checks

Vital signs

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