A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

Rationale: A. Reassess the client every 2 hours: The client is currently stable with intact neurological function, but head injuries can deteriorate rapidly. Regular reassessment every 2 hours allows early detection of changes in mental status, motor function, or vital signs, which is essential for timely intervention. B. Implement seizure precautions: Seizure precautions are indicated if the client shows signs of seizure activity or has a history of post-traumatic seizures. Since the client is alert and exhibits normal neurological function, immediate seizure precautions are not the first priority. C. Perform a Mini-Mental State Exam (MMSE): While an MMSE can provide a baseline cognitive assessment, it is not necessary as the next immediate action in a stable, alert client. Routine neurological monitoring takes priority over formal cognitive testing. D. Elevate head of bed to high Fowler’s: Elevating the head of the bed can affect intracranial pressure. For head-injured clients, the head is typically elevated to 30 degrees, not high Fowler’s, to optimize cerebral perfusion while minimizing ICP. This intervention is not the immediate next step for a neurologically stable client.