The nurse is caring for a client in intensive care with a diagnosis of traumatic brain injury. The client is found to be restless, complains of extreme nausea, and is weak on the left arm and leg. Which is the best response by the nurse?

  • check the blood pressure
  • elevate the client’s head to 30 degrees
  • administer oxygen
  • increase the IV rate
Number 2 is correct.
The client’s symptoms are consistent with increased intracranial pressure (ICP). The best immediate response is to elevate the client’s head to 30 degrees to produce a drop in ICP. Checking the blood pressure is a secondary action. Oxygen administration will not impact the increased ICP. Increasing the IV rate would be contraindicated.