# A client with a traumatic brain injury becomes increasingly drowsy and vomits. The nurse notes a widening pulse pressure. Which intervention is most appropriate?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=396593&lang=en  
> language: en  
> subject: Fluid/Electrolyte Imbalances  
> category: PA

## Question

A client with a traumatic brain injury becomes increasingly drowsy and vomits. The nurse notes a widening pulse pressure. Which intervention is most appropriate?

## Option

1. Place the client flat with the neck flexed.
2. Encourage coughing and vigorous suctioning every 5 minutes.
3. Give oral fluids to prevent dehydration.
4. Elevate the head of the bed and maintain the head in midline while notifying the provider. **✔ Correct answer**

**Correct answer: 4**

## 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.

## In-depth explanation

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 scenario

Clinical Practice Guide
For Increased intracranial pressure, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **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.

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