# A client with a traumatic brain injury has signs of increased intracranial pressure. Which nursing action is appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=394085&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

A client with a traumatic brain injury has signs of increased intracranial pressure. Which nursing action is appropriate?

## Option

1. Keep the head of bed flat with the neck flexed.
2. Elevate the head of bed about 30 degrees and keep the neck midline. **✔ Correct answer**
3. Cluster suctioning and repositioning every 4 hours only.
4. Encourage vigorous coughing to lower pressure.

**Correct answer: 2**

## 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.

## In-depth explanation

Clinical Judgment
ICP care protects cerebral perfusion by improving venous return and avoiding pressure spikes.

Memory Tip
Head up, neck straight.

## Clinical scenario

Clinical Practice Guide
Neurologic care includes airway support, oxygenation, head positioning, frequent assessment, and prevention of secondary brain injury.

Caution
Sudden neurologic decline requires immediate escalation.

## Key concepts

- **Intracranial Pressure** — Pressure inside the skull that can impair brain perfusion when elevated.
- **Cerebral Perfusion** — Blood flow that supplies oxygen and nutrients to brain tissue.
- **Midline Position** — Neutral head and neck alignment that supports venous drainage.

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