The nurse is caring for a client with increased intracranial pressure (ICP). Which statement by the unlicensed assistive personnel would require immediate intervention by the nurse?

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Clients with elevated ICP should avoid anything that increases intrathoracic or intraabdominal pressure as these also indirectly increase ICP. These activities include straining, coughing, and blowing the nose. Respiratory interventions, if needed, may include deep breathing and incentive spirometry in the absence of coughing. The head of the bed should be maintained at 30 degrees, high enough to allow for cerebrospinal fluid drainage, but low enough to maintain cerebral perfusion pressure. Clients should have minimal stimuli, including no bright lights or multiple visitors, as stimulation can increase ICP. (Option A) The head of the bed should be raised to 30 degrees and maintained. This may require follow-up, but not immediate intervention, by the nurse. (Option B) Turning down the lights is appropriate as clients with ICP benefit from a quiet, nonstimulating environment. (Option C) Bringing items closer to the client prevents straining from reaching and is appropriate. Educational objective: Clients with increased ICP should be encouraged not to cough, strain, or increase abdominal or thoracic pressure. The head of the bed should be maintained at 30 degrees, and stimulation in the room should be minimized.

The Nurse Is Caring for a Client with Increased Intracranial