Which of the following information about a client who is hospitalized after a traumatic brain injury requires the most rapid action by the nurse? A)Intracranial pressure of 15 mm Hg B)Cerebro-spinal fluid (CSF) drainage of 15 mL/hour C)Pressure of oxygen in brain tissue (PbtO₂) is 14 mm Hg D)Cardiac monitor shows sinus tachycardia, with a heart rate of 126 beats/minute

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The PbtO₂ should be 20-40 mm Hg. Lower levels indicate brain ischemia. An intracranial pressure (ICP) of 15 mm Hg is at the upper limit of normal. CSF is produced at a rate of 20-30 mL/hour. The reason for the sinus tachycardia should be investigated, but the elevated heart rate is not as concerning as the decrease in PbtO₂.

Which of the Following Information About a Client Who Is