Which finding should a nurse report as a sign of increased ICP in a client?

An important indicator of increased intracranial pressure (ICP) is the response of the pupils, which can reflect changes in brain function and pressure. Dilated pupils can signify that the pressure within the skull is affecting the oculomotor nerve, which controls pupil constriction. When ICP rises, it can lead to compression of the nerves or brain structures, resulting in pupillary dilation as a physiological response. This finding is particularly critical to assess because it can suggest worsening cerebral conditions that demand immediate medical intervention.

In contrast, increased muscle strength would typically not be associated with increased ICP, as one might expect weakness or motor deficits rather than enhancement of muscle function. Pupil constriction can also suggest a normal or even decreased ICP, particularly if it occurs in a well-functioning nervous system. A decreased respiratory rate may indicate other issues like respiratory depression and does not specifically point to changes in ICP. Thus, recognizing dilated pupils as a sign of increased ICP is vital for timely and appropriate clinical action.