A nurse is evaluating a multi-trauma client in the emergency department. The initial trauma survey has been completed and the c-spine has been cleared. The following are the nurse’s assessment findings: A&0x2 (confusion to date and time), pupils are equal at 6mm, blood pressure 182/86mmHg, heart rate 44 beats/minute, respirations 22 breaths/minute. The healthcare provider orders the head of the bed to be elevated to 30 degrees. The nurse understands that which of the following is the reason for this order?

The nurse receives report on a client on blood thinners who fell down the stairs and has periorbital ecchymosis. The head CT came back with an intracerebral hemorrhage. Which of the following is the most important to monitor closely?

A 28-year-old client has been brought into the emergency department after suffering a closed head injury from a fall. The client is demonstrating signs of the Cushing reflex. Based on the nurse’s understanding of this condition, the nurse knows to look for which of the following signs?

An early sign of increased intracranial pressure includes which of the following?

A client who has experienced a head injury is being cared for by the nurse in the ICU. The client has a monitor in place to check intracranial pressure and the nurse notes that the pressure is increasing. Which of the following interventions by the nurse should be done to control increasing intracranial pressure?

A client has sustained a head injury. Which of the following is part of the nursing plan? Select all that apply.

A nurse is caring for a client who suffering from bilateral subdural hematomas whose ICP has been ranging from 15-20 mm Hg. Which of the following orders should the nurse question?

A nurse is caring for an 8-year-old child in the ICU who has suffered a neurological injury. The nurse is monitoring the child’s intracranial pressure through the monitor and notes that it is normally about 17 to 18 mmHg but then jumps to 24 mmHg for several minutes when the nurse suctions the client’s endotracheal tube. Which of the following interventions is most appropriate?

A client who has suffered a severe brain injury is being prepared for invasive intracranial pressure monitoring. Which of the following is considered a contraindication to this type of monitor? Select all that apply.

The nurse is caring for a client with an increased intracranial pressure. Elements of the nursing plan include which of the following? Select all that apply.