A nurse is caring for a client with a severe traumatic brain injury who has an intracranial pressure (ICP) mon…

Question

A nurse is caring for a client with a severe traumatic brain injury who has an intracranial pressure (ICP) monitor in place. The client's ICP reading is 25 mmHg, and the cerebral perfusion pressure (CPP) is 55 mmHg. Which nursing intervention should the nurse implement first?

Accepted Answer

보기 3: Elevate the head of the bed to 30 degrees and ensure proper neck alignment

Elevating the head of bed to 30 degrees is the first-line, non-invasive intervention for elevated ICP, as it promotes venous drainage without requiring a physician's order. Mannitol requires an order, Trendelenburg increases ICP, and excessive fluids can worsen edema.

Answer

보기 1: Administer prescribed mannitol 1 g/kg IV push immediately

Answer

보기 2: Position the client in Trendelenburg position to improve cerebral blood flow

Answer

보기 4: Increase the rate of IV fluid administration to improve cerebral perfusion

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A nurse is caring for a client with a severe traumatic brain injury who has an intracranial pressure (ICP) monitor in place. The client's ICP reading is 25 mmHg, and the cerebral perfusion pressure (CPP) is 55 mmHg. Which nursing intervention should the nurse implement first?

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