# Situation: A 30-year-old man is in the intensive care unit after a motorcycle crash caused a severe traumatic brain injury (TBI) and a spinal cord injury at the level of the sixth cervical vertebra (C6). He is intubated and sedated, his cervical spine is immobilized, and an intraventricular catheter monitors his intracranial pressure (ICP). The unit's targets are ICP 22 mmHg or lower and cerebral perfusion pressure (CPP) 60–70 mmHg. At 04:00 his ICP has been 27 mmHg for 5 minutes. The nurse notes: bed tilted head-up 30 degrees; head rotated toward the right shoulder after a linen change; temperature 37.2 °C; oxygen saturation 98%; sedation running at the ordered rate. Orders include an as-needed sedative bolus and cerebrospinal fluid drainage for ICP above 22 mmHg. Which action should the nurse take FIRST?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630035  
> language: ko  
> subject: Nursing Practice V — Care of Clients with Maladaptive Patterns of Behavior; Care of Clients with Life-Threatening Conditions, Acute Multi-Organ Problems, High Acuity and Emergency Situations

## 문제

Situation: A 30-year-old man is in the intensive care unit after a motorcycle crash caused a severe traumatic brain injury (TBI) and a spinal cord injury at the level of the sixth cervical vertebra (C6). He is intubated and sedated, his cervical spine is immobilized, and an intraventricular catheter monitors his intracranial pressure (ICP). The unit's targets are ICP 22 mmHg or lower and cerebral perfusion pressure (CPP) 60–70 mmHg.

At 04:00 his ICP has been 27 mmHg for 5 minutes. The nurse notes: bed tilted head-up 30 degrees; head rotated toward the right shoulder after a linen change; temperature 37.2 °C; oxygen saturation 98%; sedation running at the ordered rate. Orders include an as-needed sedative bolus and cerebrospinal fluid drainage for ICP above 22 mmHg. Which action should the nurse take FIRST?

## 보기

1. Give the ordered as-needed sedative bolus
2. Drain cerebrospinal fluid through the catheter as ordered
3. Notify the provider of the sustained intracranial pressure rise
4. Realign his head and neck to a neutral midline position **✔ 정답**

**정답: 4**

## 해설

All four actions may be needed, but the nurse first corrects an obvious mechanical cause. Rotating the head compresses the jugular veins and blocks venous outflow from the skull; restoring neutral in-line alignment takes seconds, keeps the injured cervical spine protected, and may lower ICP without drugs or drainage. If ICP stays high, the ordered next-tier measures follow and the provider is informed.

## 심화 해설

Correct the obvious mechanical cause first
This client with severe traumatic brain injury has had an intracranial pressure (ICP) of 27 mmHg for 5 minutes, above the unit's target of 22 mmHg or lower. The nurse's check shows that after a linen change his head was left rotated toward the right shoulder. His temperature, oxygen saturation, head-of-bed elevation, and sedation are all as intended. Realigning his head and neck to a neutral midline position corrects a mechanical cause of raised ICP in seconds and comes first. It is quick, noninvasive, and keeps the injured cervical spine protected.

Mechanism: venous outflow from the skull
The skull contains brain tissue, blood, and cerebrospinal fluid (CSF) within a fixed space. When one volume rises, pressure rises unless another falls. Blood leaves the skull mainly through the internal jugular veins. Rotating or flexing the neck compresses these veins, slowing venous drainage so that blood volume inside the skull increases and ICP rises. Neutral alignment, with the head of the bed raised about 30 degrees, allows free venous outflow. Cervical collars that are too tight can have the same effect and are checked too.

| Action | Role | Order |
| --- | --- | --- |
| Realign head and neck to neutral midline | Corrects jugular compression | First |
| As-needed sedative bolus | Treats agitation driving ICP | If ICP stays high |
| CSF drainage through the catheter | Next-tier measure | If ICP stays high after simple causes are fixed |
| Notify the provider | Escalation | If ICP remains high |

Why the other actions follow
All four actions may be needed, but the stem asks what comes first. A sedative bolus helps when agitation or ventilator dyssynchrony drives ICP, but he is already sedated at the ordered rate and a correctable cause is visible. CSF drainage through the intraventricular catheter is a next-tier measure used if ICP stays high after simple causes are corrected. Notifying the provider is appropriate if ICP remains elevated, but fixing an obvious cause takes only seconds and should not wait.

Watch out! With a C6 spinal cord injury, realignment must keep the spine in line: use a log-roll technique and enough staff to maintain in-line stabilization. Also check the cerebral perfusion pressure (CPP), calculated as mean arterial pressure minus ICP, against the target of 60 to 70 mmHg.

Exam takeaway
Key point! When ICP rises, first check simple, correctable causes: head and neck position, head-of-bed angle, tight collars or ties, temperature, oxygenation, and pain or agitation. Escalate to drugs, CSF drainage, and the provider if ICP stays high.

## 임상 시나리오

Raised ICP After RepositioningRestore venous outflow first
ICP of 27 mmHg with the head rotated after a linen change points to jugular venous compression.

Realign the head and neck to neutral midline with the head of the bed at 30 degrees. Keep in-line stabilization because of the C6 injury.

If ICP stays above 22 mmHg, use the ordered sedative bolus or CSF drainage and inform the provider. Keep CPP at 60 to 70 mmHg.

CautionCheck for simple mechanical causes before drugs or drainage, and never twist the neck of a client with a cervical spine injury.

## 핵심 개념

- **Intracranial pressure** — The pressure inside the skull, which rises when brain, blood, or CSF volume increases.
- **Cerebral perfusion pressure** — Mean arterial pressure minus ICP; the pressure that drives blood flow to the brain.
- **Intraventricular catheter** — A catheter in a brain ventricle that measures ICP and allows CSF drainage.
- **Jugular venous drainage** — Outflow of blood from the skull through the jugular veins, impeded by neck rotation or flexion.

## 같은 주제 문제

- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630016)
- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630017)
- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630018)
- [Situation: A 58-year-old man with severe community-acquired pneumonia is intubated in the …](https://mymerci.kr/pages/nclex_q.php?qn_id=630019)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630020)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630021)
- [Situation: A 62-year-old man arrives at the emergency department of a provincial hospital …](https://mymerci.kr/pages/nclex_q.php?qn_id=630022)
- [Situation: A 70-year-old woman with rheumatic heart disease is in the coronary care unit. …](https://mymerci.kr/pages/nclex_q.php?qn_id=630023)

---

More free questions: [기출문제](https://mymerci.kr/)

_학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._