# A nurse is caring for a client with a severe traumatic brain injury who has been admitted to the intensive care unit. The client's intracranial pressure (ICP) monitoring shows a reading of 25 mmHg, and the client exhibits decerebrate posturing. Which nursing intervention should be the nurse's immediate priority? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541140 > language: ko > subject: Adult Health ## 문제 A nurse is caring for a client with a severe traumatic brain injury who has been admitted to the intensive care unit. The client's intracranial pressure (ICP) monitoring shows a reading of 25 mmHg, and the client exhibits decerebrate posturing. Which nursing intervention should be the nurse's immediate priority? ## 보기 1. Elevate the head of the bed to 30 degrees and maintain neutral head alignment **✔ 정답** 2. Administer prescribed mannitol intravenously as ordered 3. Hyperventilate the client to achieve PaCO2 of 25-30 mmHg 4. Prepare the client for immediate surgical intervention **정답: 1** ## 해설 Elevating the head of the bed to 30 degrees with neutral alignment is the immediate priority to promote venous drainage and reduce ICP. Other interventions require physician orders or are less immediate. ## 심화 해설 Clinical Priority Analysis The client presents with a severe traumatic brain injury (TBI), an intracranial pressure (ICP) reading of 25 mmHg (sustained elevation above the treatment threshold of 20-22 mmHg), and decerebrate posturing, which indicates significant brainstem dysfunction and a worsening neurological state. This combination signals a critical risk for secondary brain injury due to compromised cerebral perfusion. The immediate nursing priority is to implement interventions that rapidly and safely lower ICP without causing additional harm, following a least-invasive-first approach. Why Elevating the Head of the Bed is the Immediate Priority Elevating the head of the bed to 30 degrees with neutral head alignment is a foundational, non-invasive intervention that promotes cerebral venous outflow. By using gravity to facilitate venous drainage from the brain, this positioning directly reduces intracranial blood volume, which is a key component of ICP. Maintaining a neutral head alignment is equally critical; any flexion, extension, or rotation of the neck can compress the jugular veins, obstructing venous return and paradoxically increasing ICP. This intervention is low-risk, can be performed immediately by the nurse without a provider's order under standing protocols, and serves to stabilize the patient while other therapies are prepared. The review of ventilatory strategies in acute brain injury emphasizes that the preservation of ICP and cerebral perfusion pressure (CPP) relies on such fundamental physiological positioning principles [1]. Analysis of Alternative Options - Option 2: Administer prescribed mannitol intravenously. While osmotic diuretics like mannitol are a cornerstone of pharmacological ICP management, their administration is not the immediate first step. The nurse must first ensure the patient's position is optimized to maximize the drug's effectiveness. Furthermore, mannitol administration requires careful preparation, verification of the order, and IV access assessment. The positioning maneuver can be completed in seconds, providing an immediate bridge to pharmacotherapy. - Option 3: Hyperventilate the client to achieve PaCO2 of 25-30 mmHg. Prophylactic hyperventilation to a PaCO2 below 35 mmHg is no longer a standard first-line intervention. While a reduction in PaCO2 causes cerebral vasoconstriction and can transiently lower ICP, aggressive hyperventilation can induce cerebral ischemia by reducing cerebral blood flow too drastically. Current evidence-based recommendations prioritize individualized ventilator settings that preserve ICP and CPP, and hyperventilation is typically reserved for acute, refractory ICP spikes as a temporizing measure while other treatments are initiated [1]. - Option 4: Prepare the client for immediate surgical intervention. Surgical decompression is a life-saving procedure for refractory intracranial hypertension, but it is a definitive, not an immediate, intervention. The nurse's priority is to exhaust all rapid, bedside, non-invasive strategies first. Preparing for surgery involves a series of steps (consent, team assembly, operating room preparation) that occur concurrently with, but not before, basic physiological maneuvers like head-of-bed elevation. Integration of Ventilatory Strategy Evidence The contemporary approach to managing severe acute brain injury, as highlighted in the provided evidence synthesis, stresses the importance of individualizing care to target ICP and CPP. This begins with basic physiological tenets, such as optimizing patient positioning to enhance venous outflow, before progressing to more complex ventilatory or pharmacological manipulations. The principle of prioritizing a physiological target over a specific mode of therapy directly supports the rationale that a simple, nurse-driven positioning adjustment is the correct first response to an elevated ICP reading [1].References (research sources) - [1]Brain Protective Ventilation Strategies in Severe Acute Brain Injury.Research articleSharie SA, Almari R, Azzam S, Al-Husinat L, Araydah M, Battaglini D, Schultz MJ, Patroniti NA, Rocco PR, Robba C. (2025) · DOI: 10.1007/s11910-025-01462-2 ## 임상 시나리오 ICP Crisis: Immediate Nursing ActionPrioritizing non-invasive positioning for cerebral drainage For a patient with severe TBI and an ICP of 25 mmHg, the first action is to elevate the head of bed to 30 degrees and ensure neutral head alignment. This uses gravity to promote cerebral venous outflow, directly reducing intracranial blood volume. Maintaining a neutral neck position is critical; any flexion, extension, or rotation can compress the jugular veins, obstructing venous return and paradoxically increasing ICP. This intervention is low-risk, requires no order, and can be done immediately. CautionAvoid routine hyperventilation to a PaCO2 of 25-30 mmHg. This causes cerebral vasoconstriction and can lead to ischemia. It is reserved only for acute herniation syndromes. Always follow a least-to-most invasive approach. ## 핵심 개념 - **Decerebrate posturing** — Abnormal extension of the upper and lower extremities indicating severe brainstem damage and a worsening neurological state. - **Intracranial Pressure (ICP)** — The pressure inside the skull; sustained elevation above 20-22 mmHg is a treatment threshold to prevent secondary brain injury. - **Cerebral perfusion pressure (CPP)** — The net pressure gradient driving blood flow to the brain, calculated as mean arterial pressure (MAP) minus ICP. - **Mannitol** — An osmotic diuretic used to draw fluid from brain tissue into the vasculature to lower ICP, requiring a provider's order. ## 같은 주제 문제 - [A nurse is caring for a client who sustained a severe traumatic brain injury 48 hours ago.…](https://mymerci.kr/pages/nclex_q.php?qn_id=541131) - [A nurse is caring for a client who sustained a severe traumatic brain injury 6 hours ago. …](https://mymerci.kr/pages/nclex_q.php?qn_id=541132) - [A nurse is caring for a client with a severe traumatic brain injury who has an intracrania…](https://mymerci.kr/pages/nclex_q.php?qn_id=541133) - [A nurse is caring for a client with a severe traumatic brain injury who has been experienc…](https://mymerci.kr/pages/nclex_q.php?qn_id=541134) - [A nurse is caring for a client with a severe traumatic brain injury who has an intracrania…](https://mymerci.kr/pages/nclex_q.php?qn_id=541135) - [A nurse is caring for a client who sustained a severe traumatic brain injury in a motor ve…](https://mymerci.kr/pages/nclex_q.php?qn_id=541136) - [A nurse is caring for a client who sustained a severe stroke 6 hours ago. 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