A client with a traumatic brain injury has signs of increased intracranial pressure. Which nursing action is appropriate?
1Elevate the head of bed about 30 degrees and keep the neck midline.✓ Correct answer
2Keep the head of bed flat with the neck flexed.
3Encourage vigorous coughing to lower pressure.
4Cluster suctioning and repositioning every 4 hours only.
Explanation
For increased intracranial pressure, positioning the head midline with the head of bed elevated helps promote venous drainage. Neck flexion, prolonged clustering, and vigorous coughing can increase intracranial pressure. The nurse also monitors neurologic status closely.
Clinical Judgment ICP care protects cerebral perfusion by improving venous return and avoiding pressure spikes.
Memory Tip Head up, neck straight.
Clinical Practice GuideNeurologic care includes airway support, oxygenation, head positioning, frequent assessment, and prevention of secondary brain injury.