Question

The nurse cares for a client with traumatic brain injury. The nurse notes the client's intracranial pressure (ICP) is elevating. Which actions does the nurse perform to decrease the ICP?

Select all that apply.

1) Administer mannitol as prescribed.
2) Assess pupil reactivity.
3) Monitor oxygen saturation.
4) Position the head in a midline, neutral position.
5) Maintain normal temperature and blood pressure ranges according to client baseline.

Answer 1

The nurse can decrease intracranial pressure (ICP) in a client with traumatic brain injury by administering mannitol, positioning the head in a midline neutral position, and maintaining normal temperature and blood pressure.

Step-by-step explanation:

To decrease intracranial pressure (ICP) in a client with traumatic brain injury, the nurse should perform the following actions:

1. Administer mannitol as prescribed: Mannitol is an osmotic diuretic that helps reduce ICP by drawing fluid out of the brain and into the bloodstream, decreasing the total volume of cerebrospinal fluid in the limited space inside the skull.
2. Position the head in a midline, neutral position: This position helps optimize cerebral venous drainage and prevents further increases in ICP.
3. Maintain normal temperature and blood pressure ranges according to client baseline: Elevated temperature and blood pressure can increase cerebral metabolic demand and contribute to an increase in ICP.

The nurse should also assess pupil reactivity and monitor oxygen saturation as part of the overall assessment but these actions do not directly decrease ICP.