A client with a traumatic brain injury becomes increasingly drowsy and vomits. The nurse notes a widening pulse pressure. Which intervention is most appropriate?
1Instruct the client to cough forcefully and perform deep tracheal suctioning every 1 to 2 hours.
2Elevate the head of the bed and maintain the head in midline while notifying the provider.✓ Correct answer
3Keep the client flat with the head turned to the side and the neck flexed to prevent aspiration.
4Provide oral fluids in small, frequent amounts to prevent dehydration and maintain cerebral perfusion.
Explanation
Deteriorating level of consciousness, vomiting, and widening pulse pressure can indicate increased intracranial pressure. Head elevation and midline positioning support venous drainage while urgent notification occurs. Neck flexion, excessive stimulation, or oral intake can worsen risk.
Clinical Judgment Use the client cues, timing, labs, and safety risks to select the response that best fits Increased intracranial pressure.
Memory Tip Match the strongest cue cluster to the safest nursing judgment.
KR vs US NCLEX items reward cue-based priority thinking rather than isolated recall.
Clinical Practice GuideFor Increased intracranial pressure, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.
CautionDo not choose an action from one isolated cue when the full scenario changes priority or safety.
Intracranial Pressure — Pressure inside the skull that can rise after brain injury.
Level of Consciousness — A key neurologic indicator of brain function and deterioration.
Midline Position — Keeping the head aligned to promote venous drainage from the brain.