hard · NCLEX-RN physiological
A 24-year-old client is admitted to the intensive care unit following a traumatic brain injury. The nurse notes the client has become increasingly lethargic, and the latest intracranial pressure (ICP) reading is 22 mm Hg. Which actions should the nurse implement to manage the rising pressure? Select all that apply.
- Ensure the cervical collar is not fit too tightly around the neck
- Administer prescribed stool softeners to prevent straining
- Perform vigorous nasopharyngeal suctioning every hour
- Maintain a calm, low-stimulus environment with dimmed lights
- Group all nursing care activities to allow for long rest periods
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