The nurse is caring for a client who has a systemic BP of 108/51 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which of the following actions should the nurse take first?
A)Elevate the head of the client's bed to 60 degrees.
B)Document the BP and ICP in the client's record.
C)Report the BP and ICP to the health care provider.
D)Continue to monitor the client's vital signs and ICP.

Question

Quizplus · Accepted Answer

The client's cerebral perfusion pressure is 56 mm Hg, below the normal of 70-100 mm Hg and approaching the level of ischemia and neuronal death as a minimum of 50-60 mm Hg is necessary for adequate cerebral perfusion. Immediate changes in the client's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation also will be done, but they are not the first actions that the nurse should take.

The Nurse Is Caring for a Client Who Has a Systemic