Exhibits

Rationale for Correct Choices • Increased intracranial pressure (ICP): The client’s fall, head trauma, amnesia regarding the event, double vision, and sluggish pupillary reaction are classic signs of elevated ICP. Headache and neurologic changes further support this condition. • Elevate the head of the bed 40 degrees: Elevating the head promotes venous drainage from the brain and helps reduce intracranial pressure, which is critical for a patient showing signs of head trauma. • Start supplemental oxygen: Maintaining adequate oxygenation prevents hypoxia, which can worsen brain injury and increase ICP. Oxygen support helps stabilize the client while further evaluation is conducted. • Glasgow Coma Scale (GCS): Monitoring GCS assesses the client’s neurological status and detects worsening ICP or neurologic deterioration. Changes in level of consciousness are key indicators. • Blood pressure: Elevated ICP can cause Cushing’s triad (hypertension, bradycardia, irregular respirations), so monitoring blood pressure helps detect worsening neurologic status. Rationale for Incorrect Choices • Push fluids: Aggressive fluid administration is not indicated and may worsen cerebral edema or increase ICP. Fluid management should be carefully controlled in head injury patients. • Call for a 12-lead ECG: There is no evidence of cardiac compromise in the assessment; heart rate and rhythm are stable, so ECG is not immediately necessary. • Give aspirin: Antiplatelet therapy is contraindicated in acute head trauma due to the risk of intracranial bleeding. Administering aspirin could exacerbate hemorrhage. • Myocardial infarction: The client’s symptoms are neurologic rather than cardiac; chest pain, diaphoresis, or cardiac ischemic changes are absent. • Transient ischemic attack (TIA): While TIA involves neurologic changes, the acute trauma with head injury and amnesia points toward elevated ICP, not a vascular transient event. • Thrombotic stroke: The presentation is trauma-related, not consistent with an ischemic stroke; sudden double vision and head trauma make ICP more likely than thrombosis. • Parameter – Heart rhythm / Apical pulse: While important in general assessment, there are no current indications of arrhythmia, so continuous monitoring is not the priority. • Temperature: There is no fever or infection suspected; temperature monitoring is not immediately relevant to ICP in this scenario. • Blood glucose: Blood glucose is not indicated in the acute assessment of traumatic brain injury unless the patient is diabetic or showing metabolic symptoms; not a priority here.