The intracranial pressure (ICP) of a brain injured client who is on a ventilator has increased from 15 mm Hg to 25 mm Hg within the last 30 minutes. The client is beginning to flex all extremities intermittently. Based on these findings, which immediate action should the nurse take? Reference Range: Increased cranial pressure (ICP) [7 to 15 mm Hg]

Rationale: A. Manually ventilate the client using the ambu bag: Manual ventilation can increase intrathoracic pressure and inadvertently worsen intracranial pressure if performed without a clear indication or synchronized settings. It should only be done if the ventilator or airway is malfunctioning, not as an initial response to rising ICP. B. Assess the patency of the client's artificial airway: A sudden rise in ICP with posturing may result from hypoxia or hypercapnia caused by airway obstruction or poor ventilation. This is the most immediate nursing action to restore adequate oxygenation and prevent further neurological deterioration. C. Administer the prescribed PRN dose of morphine sulfate IV: Morphine can cause respiratory depression, CO₂ retention, and cerebral vasodilation, which can further elevate intracranial pressure. Analgesics may be given later for comfort, but they are not the priority. D. Draw a stat arterial blood gas to assess for hypercapnia: Although evaluating CO₂ levels helps determine the cause of increased ICP, obtaining and processing the blood sample takes time. The nurse should first ensure the airway is clear and ventilation adequate before proceeding with diagnostic measures.