Which of the following is NOT an early sign of increased intracranial pressure in a head-injured patient?

• A. Altered level of consciousness
• B. Nausea and vomiting
• C. Headache
• D. Dilated or non-reactive pupil

Answer: (D)

The key idea is distinguishing early signs of rising intracranial pressure from signs that appear later as pressure continues to worsen. Early ICP effects generally hit brain function and the meninges first: a patient may become confused or have altered level of consciousness as cerebral function is impaired, and headache occurs from meningeal stretching. Nausea and vomiting are common early symptoms due to pressure on the brainstem’s vomiting centers and impaired autoregulation. In contrast, pupil dilation or a non-reactive pupil tends to appear later, as ICP rises enough to compress the third cranial nerve and herald impending brain herniation. That makes dilated or non-reactive pupils a sign of progression toward herniation rather than an initial early sign. So the option describing a dilated or non-reactive pupil is not an early sign, whereas altered consciousness, nausea/vomiting, and headache are typical early indicators of increasing ICP.