# A nurse is assessing a patient with a suspected brain injury. Which assessment finding would indicate increased intracranial pressure (ICP)? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541088 > language: ko > subject: Adult Health ## 문제 A nurse is assessing a patient with a suspected brain injury. Which assessment finding would indicate increased intracranial pressure (ICP)? ## 보기 1. Blood pressure 110/70 mmHg, pulse 88 bpm, respirations 16/min 2. Alert and oriented to person, place, and time with normal speech patterns 3. Pupils equal, round, and reactive to light bilaterally 4. Bradycardia with widening pulse pressure and irregular respirations **✔ 정답** **정답: 4** ## 해설 Cushing's triad (bradycardia, widening pulse pressure, irregular respirations) is a classic late sign of increased ICP. Other options represent normal or non-specific findings not indicative of elevated ICP. ## 심화 해설 Correct Answer: 4. Bradycardia with widening pulse pressure and irregular respirations This combination of vital sign changes is the classic manifestation of Cushing's triad, a late and critical sign of markedly elevated intracranial pressure (ICP). Understanding the pathophysiology behind this response is essential for early recognition of a life-threatening ICP crisis. Pathophysiology of Cushing's Triad When ICP rises, it compresses cerebral blood vessels, reducing cerebral perfusion pressure (CPP). The brainstem detects this ischemia and triggers a powerful compensatory response to maintain cerebral blood flow. 1. Widening Pulse Pressure (Hypertension): The systolic blood pressure rises dramatically in an attempt to overcome the high ICP and force blood into the brain. The diastolic pressure remains relatively stable or increases only slightly, causing the pulse pressure (the difference between systolic and diastolic) to widen. This is a reflexive response to cerebral ischemia. 2. Bradycardia: The baroreceptors in the carotid sinus and aortic arch sense the systemic hypertension and trigger a parasympathetic (vagal) response, which slows the heart rate. As noted in the literature, this is a form of true bradycardia resulting from a physiological response to high ICP, distinct from relative bradycardia seen in other trauma settings [1]. This brain-heart interaction is a direct consequence of autonomic imbalance driven by intracranial pathology [1]. 3. Irregular Respirations: As ICP continues to rise, it causes compression and herniation of the brainstem, directly affecting the respiratory centers in the medulla oblongata. This leads to abnormal respiratory patterns, which can progress from Cheyne-Stokes respirations to ataxic breathing and, ultimately, apnea. Analysis of Incorrect Options Options 1, 2, and 3 are all normal or expected assessment findings that do not indicate a pathological increase in ICP. - Option 1: A blood pressure of 110/70 mmHg, pulse of 88 bpm, and respirations of 16/min are all within normal limits for an adult. These findings contradict the hypertensive, bradycardic, and irregular breathing pattern of Cushing's triad. - Option 2: A patient who is alert and oriented to person, place, and time with normal speech patterns demonstrates a normal level of consciousness and intact cortical function. Increased ICP typically causes a progressive decline in consciousness, from confusion and lethargy to obtundation and coma, as cerebral perfusion is compromised . - Option 3: Pupils that are equal, round, and reactive to light bilaterally (PERRLA) indicate intact function of cranial nerves II and III (oculomotor nerve). A late and ominous sign of increased ICP with uncal herniation is a unilateral, fixed, and dilated pupil on the ipsilateral side due to compression of the oculomotor nerve. Bilateral fixed and dilated pupils signify catastrophic brainstem damage. Clinical Significance and Monitoring The appearance of Cushing's triad signals that the brain's compensatory mechanisms are failing and an ICP crisis is imminent. While invasive ICP monitoring via a catheter remains the gold standard for diagnosis and management, it is not always immediately available or feasible in all settings . Therefore, the nurse's ability to recognize this clinical syndrome through vital sign assessment is a critical, non-invasive indicator of a devastating condition . Prompt recognition and reporting of these findings allow for immediate interventions—such as elevating the head of the bed, ensuring adequate oxygenation and ventilation, and administering hyperosmolar therapy like hypertonic saline—to prevent irreversible brain injury from herniation .References (research sources) - [1]Scoping Review on True and Relative Bradycardia in Trauma: How to Approach Bradycardia in Traumatic Brain Injury.Research articleEl-Menyar A, Khan NA, Abid AR, Elmenyar E, Al-Thani H. (2026) · DOI: 10.1007/s12265-026-10772-w ## 임상 시나리오 Recognizing Cushing's TriadA Late Sign of Increased Intracranial Pressure Cushing's triad is a critical, late-stage sign of markedly elevated intracranial pressure (ICP). It signals that the brain's compensatory mechanisms are failing and brainstem herniation is imminent. The triad consists of three vital sign changes resulting from cerebral ischemia and autonomic imbalance: Widening Pulse Pressure (systolic hypertension with a stable or slightly increased diastolic pressure), Bradycardia (a vagal response to systemic hypertension), and Irregular Respirations (caused by brainstem compression). CautionDo not mistake a rising systolic blood pressure as a positive sign. In a patient with a head injury, this finding with a slowing heart rate is a medical emergency requiring immediate intervention to reduce ICP. Report these findings instantly. ## 핵심 개념 - **Cushing's Triad** — A late and critical sign of increased intracranial pressure characterized by bradycardia, widening pulse pressure (hypertension), and irregular respirations. - **Widening Pulse Pressure** — An increase in the difference between systolic and diastolic blood pressure, occurring as the systolic pressure rises to overcome high ICP while diastolic remains relatively stable. - **Cerebral Perfusion Pressure (CPP)** — The net pressure gradient driving blood flow to the brain, calculated as Mean Arterial Pressure (MAP) minus Intracranial Pressure (ICP). ## 같은 주제 문제 - [A nurse is assessing a 65-year-old patient with a suspected neurological disorder. Which a…](https://mymerci.kr/pages/nclex_q.php?qn_id=541087) - [A nurse is assessing a patient with a suspected neurological disorder. 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