# A client in the neuro ICU 6 hours after severe TBI has an ICP monitor reading 24 mm Hg sustained for 8 minutes and MAP 78 mm Hg. Which intervention should the nurse implement FIRST?

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> url: https://mymerci.kr/pages/nclex_q.php?qn_id=374964&lang=en  
> language: en  
> subject: NCLEX-RN  
> category: PA

## Question

A client in the neuro ICU 6 hours after severe TBI has an ICP monitor reading 24 mm Hg sustained for 8 minutes and MAP 78 mm Hg. Which intervention should the nurse implement FIRST?

## Option

1. Verify head-of-bed at 30 degrees and that the neck is in neutral midline alignment **✔ Correct answer**
2. Administer 23.4 percent hypertonic saline bolus
3. Hyperventilate to a target PaCO2 of 28 mm Hg
4. Decrease propofol to allow a neurologic exam

**Correct answer: 1**

## Explanation

Tier-1 ICP control begins with optimizing simple physiologic factors: HOB elevation 30 degrees, neutral neck alignment to promote jugular drainage, adequate sedation/analgesia, and normocapnia. These are verified BEFORE escalating to hyperosmolar therapy. Hypertonic saline is appropriate but is a tier-2 intervention. Prophylactic hyperventilation to PaCO2 below 30 causes cerebral vasoconstriction and ischemia and is reserved for impending herniation. Lightening sedation increases ICP.

## In-depth explanation

Brain Trauma Foundation tier-1 bundle: position, sedation, normocapnia, normothermia, CSF drainage. Reflex hyperventilation is OUT of guidelines except as a brief bridge to surgery.

## Clinical scenario

GCS 7T, intubated, sedated with propofol. HOB at 30 degrees, neck midline. PaCO2 38 mm Hg on mechanical ventilation. Most recent CPP 54 mm Hg.

## Key concepts

- **cerebral perfusion pressure** — CPP = MAP - ICP; target 60-70 mm Hg in adult TBI.
- **hyperosmolar therapy** — Hypertonic saline or mannitol used to reduce cerebral edema.
- **Monro-Kellie doctrine** — Fixed cranial volume principle: increase in one component (blood, CSF, brain) raises ICP unless another decreases.

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