Question

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority?
1. Moving the client as little as possible
2. Preparing the client for mannitol administration
3. Stimulating the client to maintain responsivenes
4. Monitoring the client for increasing intracranial pressure

Answer 1

Answer:

Answer is 4. Monitoring the client for increasing intracranial pressure.

Refer below.

Explanation:

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. The nursing action takes priority:

Monitoring the client for increasing intracranial pressure