A 45-year-old patient with a severe traumatic brain injury is in the ICU. The nurse notes an increase in systolic blood pressure, a decrease in heart rate, and irregular respirations. Which of the following conditions is the patient most likely exhibiting, and what is the priority nursing intervention?
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A 45-year-old patient with a severe traumatic brain injury is in the ICU. The nurse notes an increase in systolic blood pressure, a decrease in heart rate, and irregular respirations. Which of the following conditions is the patient most likely exhibiting, and what is the priority nursing intervention?
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Septic shock. Administer broad-spectrum antibiotics and fluid resuscitation.
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Autonomic dysreflexia. Check for bladder distension and administer antihypertensives.
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Hypovolemic shock. Rapidly infuse crystalloid solutions.
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Cushing's triad. Elevate the head of the bed to 30 degrees and maintain midline alignment.
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