# A nurse is caring for a 52-year-old client admitted to the neuro ICU with a confirmed grade III subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm. The client was endovascularly coiled 4 hours ago. Current findings: GCS 12, blood pressure 168/94 mm Hg, heart rate 56 (down from 78), pupils 3 mm reactive, with progressively worsening headache. The external ventricular drain (EVD) is set at 15 cm above the tragus and shows minimal CSF output over the past hour. Which actions should the nurse take? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=368107&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A nurse is caring for a 52-year-old client admitted to the neuro ICU with a confirmed grade III subarachnoid hemorrhage from a ruptured anterior communicating artery aneurysm. The client was endovascularly coiled 4 hours ago. Current findings: GCS 12, blood pressure 168/94 mm Hg, heart rate 56 (down from 78), pupils 3 mm reactive, with progressively worsening headache. The external ventricular drain (EVD) is set at 15 cm above the tragus and shows minimal CSF output over the past hour. Which actions should the nurse take? Select all that apply.

1

Verify the EVD setup by comparing the zero-reference point to the tragus and ensure the stopcock is open to drainage

2

Position the client supine with the head of bed flat to maximize cerebral perfusion pressure and reduce the risk of vasospasm

3

Administer a 1 L bolus of 0.9% normal saline rapidly to augment blood pressure and cerebral perfusion in light of the bradycardia

4

Notify the neurosurgeon immediately about the new bradycardia, widened pulse pressure, and worsening headache suggestive of intracranial hypertension

5

Avoid suctioning, hip flexion, isometric exercises, and any Valsalva maneuvers that could further raise intracranial pressure

6

Maintain the head of bed at 30 degrees with the neck in neutral alignment to optimize venous outflow

## Explanation

Post-rupture SAH with new bradycardia (78 to 56), widening pulse pressure (168/94, PP 74), and worsening headache is the Cushing triad — a late and ominous sign of intracranial hypertension. Critical actions: (1) immediate neurosurgeon notification; (2) verify EVD setup — minimal output may signal an occluded line, malposition relative to the tragus reference, or a clamped stopcock; (4) head of bed at 30 degrees with neutral neck optimizes venous return without compromising perfusion; (5) avoid all activities that raise ICP (Valsalva, suctioning without preoxygenation, hip flexion, isometric exercises). HOB flat (option 2) raises ICP. A rapid 1 L crystalloid bolus (option 3) without targeted hemodynamic goals can worsen cerebral edema; SAH protocols use modest euvolemic targets and selective HHH therapy when vasospasm develops.

## In-depth explanation

Cushing Triad — Late ICP Sign
Bradycardia + widened pulse pressure + irregular respirations equals imminent herniation. By this stage the intervention window is minutes.

EVD Quick-Check
1. Zero-reference at the tragus (foramen of Monro level)
2. Stopcock open to drainage
3. CSF column oscillates with pulse and respiration
4. Output trends — sudden drop calls for checking tubing kinks, level, occlusion

ICP Hygiene
- HOB 30 degrees, neck neutral
- No Valsalva (no straining, hip flexion, isometric)
- Preoxygenate before brief (less than 10 second) suctioning
- Quiet, low-stimulation environment

Wrong Answers
3: HOB flat raises ICP.
6: Aggressive 1 L bolus risks worsening cerebral edema.

NCSBN Theme
PA — Medical emergency / neurological.

## Clinical scenario

Scenario
52-year-old, grade III SAH from ruptured AcomA aneurysm, endovascular coiling 4 hours ago, neuro ICU.

Current Findings
- GCS 12
- BP 168/94 (PP 74)
- HR 56 (down from 78)
- Pupils 3 mm reactive
- Worsening headache
- EVD at 15 cm above tragus, minimal CSF output

Pattern Recognition
Bradycardia plus widening pulse pressure plus worsening headache equals Cushing triad / impending herniation. Minimal EVD output prompts a setup, occlusion, and level check.

## Key concepts

- **Subarachnoid Hemorrhage (SAH)** — Bleeding into the subarachnoid space, most often from a ruptured cerebral aneurysm. Classic onset: thunderclap worst-headache-of-life. Hunt-Hess and WFNS grading systems guide prognosis. Acute risks: rebleeding (peaks day 0 to 1), hydrocephalus (treated with EVD), vasospasm or delayed cerebral ischemia (peaks day 4 to 14, treated with nimodipine and HHH), seizures, and hyponatremia (CSW).
- **Cushing triad** — Late sign of severely elevated ICP indicating impending brainstem herniation: bradycardia, widening pulse pressure (rising systolic with stable or falling diastolic), and irregular respirations (Cheyne-Stokes or apneustic). Requires immediate intervention — hyperosmolar therapy, hyperventilation bridge, surgical decompression.
- **External ventricular drain (EVD)** — Catheter placed in the lateral ventricle for ICP monitoring and CSF drainage. Zero-referenced to the tragus (level of the foramen of Monro). Adjusted height in cm above the tragus determines the drainage threshold. Always confirm level, stopcock direction, oscillation, and output trend. Sudden zero output may indicate occlusion, a displaced level, or stopcock closed to drainage.

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