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Medicine General 5100b536

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

A
Reposition the client to avoid neck flexion
B
Administer 1 g Mannitol IV as ordered
C
Increase the ventilator’s respiratory rate to 20 breaths/minute
D
Administer 100 mg of pentobarbital IV as ordered.
High-Yield Explanation
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.

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