Question

The nurse cares for a client with traumatic brain injury on continuous mechanical ventilation. The nurse assesses sluggish pupils and an increase in blood pressure. Which intervention does the nurse implement first?

1) Palpate carotid and radial pulses noting rate, strength, and regularity.
2) Dim room lights, turn off the TV, and quiet machine alarms if possible.
3) Auscultate four quadrants of the client's abdomen to complete assessment.
4) Call the HCP to recommend and request to hyperventilate the client.

Answer 1

The nurse should dim the room lights, turn off the TV, and quiet machine alarms if possible.

Step-by-step explanation:

In this scenario, the nurse is caring for a client with traumatic brain injury on continuous mechanical ventilation.

The nurse assesses sluggish pupils and an increase in blood pressure. The first intervention the nurse should implement is to dim the room lights, turn off the TV, and quiet machine alarms if possible.

This is because the client's symptoms suggest a potential increase in intracranial pressure, and a quiet and dim environment can help reduce stimulation and promote cerebral perfusion.