Question

A client with a neurological injury (eg, head trauma, stroke) is at risk for cerebral edema and increased intracranial pressure (ICP), a life-threatening situation. The client with atrial fibrillation may also be taking anticoagulants (eg, warfarin, rivaroxaban, apixaban, dabigatran), making a life-threatening intracranial bleed even more dangerous. The nurse should perform a neurologic assessment (eg, level of consciousness, pupil response, vital signs) immediately.

(Option 1) Autonomic dysreflexia (eg, throbbing headache, flushing, hypertension) is a life-threatening condition caused by sensory stimulation that occurs in clients who have a spinal cord injury at T6 or higher. This is not the priority assessment as this client's injury is at L3. This client likely has acute urinary retention and needs catheterization.

(Option 2) Phenytoin toxicity commonly presents with neurologic manifestations such as gait disturbance, slurred speech, and nystagmus. These are expected symptoms and therefore are not a priority.

(Option 3) A brain tumor can also cause increased intracranial pressure; clients report morning headache, nausea, and vomiting. Dexamethasone (Decadron) can be prescribed short-term to decrease the surrounding edema. A tumor usually grows more slowly than a possible hematoma and is therefore not the priority assessment.

Educational objective:
Constant headache, decreased mental status, and sudden-onset emesis indicate increased intracranial pressure.

Answer 1

The priority assessment for a client with a neurological injury at risk for increased intracranial pressure is a neurologic assessment, including the evaluation of level of consciousness, pupil response, and vital signs. Constant headache, decreased mental status, and sudden-onset emesis indicate increased intracranial pressure.

Step-by-step explanation:

Based on the information provided, the primary topic of this question is neurological assessment in clients with neurological injury and the risk of increased intracranial pressure. When a client with a neurological injury, such as head trauma or stroke, is at risk for cerebral edema and increased intracranial pressure, it is crucial for the nurse to perform a neurologic assessment immediately. This assessment includes evaluating the client's level of consciousness, pupil response, and vital signs.

The presence of constant headache, decreased mental status, and sudden-onset emesis indicates increased intracranial pressure, making it a priority to assess and address. Autonomic dysreflexia, phenytoin toxicity, and brain tumor are also mentioned in the options but are not the priority assessments in this scenario. Autonomic dysreflexia is more common in clients with spinal cord injuries at T6 or higher, while this client's injury is at L3. Phenytoin toxicity presents with neurologic manifestations, but these are expected symptoms and not a priority. Brain tumors can cause increased intracranial pressure, but they usually grow more slowly than a possible hematoma and are therefore not the priority assessment.