A nurse is planning care for a client who has a severe traumatic brain injury (TBI). Which of the following should the nurse include in the plan of care? (Select all that apply)

Choice A rationale Assessing for cough reflex is crucial in a client with severe TBI to evaluate brainstem function and protect against aspiration. Impaired cough reflex indicates potential neurological compromise, increasing the risk of pulmonary complications like pneumonia due to inability to clear secretions effectively. Choice B rationale Assessing for abnormal posturing, such as decorticate or decerebrate rigidity, provides vital information about the extent and location of brainstem damage. These postures signify severe neurological dysfunction and elevated intracranial pressure (ICP), indicating a critical need for immediate intervention. Choice C rationale Assessing for Cushing's Triad, which includes bradycardia, hypertension (especially widening pulse pressure), and irregular respirations, is paramount as it indicates significantly increased intracranial pressure (ICP) and impending brain herniation. This is a late and ominous sign requiring immediate medical intervention. Normal pulse rate is 60-100 beats/minute. Choice D rationale The palmar reflex, a primitive reflex, is typically present in infants and disappears around 5-6 months of age. Its presence in an adult with TBI does not provide meaningful information regarding acute neurological status or brain injury severity, unlike more pertinent brainstem or motor assessments. Choice E rationale Assessing the ability to follow simple commands provides a rapid and essential evaluation of the client's cognitive function, level of consciousness, and intactness of motor pathways. This assessment helps determine the client's Glasgow Coma Scale (GCS) score, guiding further management and prognosis.