An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first
The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP.
Options B, C, and D: If nursing measures prove ineffective notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.
Reposition the client to avoid neck flexion
Administer 1 g Mannitol IV as ordered
Increase the ventilator’s respiratory rate to 20 breaths/minute
Administer 100 mg of pentobarbital IV as ordered.