Which of the following are nursing priorities for a child with severe traumatic brain injury (TBI)?

Choice A rationale Elevating the head of bed (HOB) to 15-30° promotes optimal cerebral venous drainage, which assists in reducing intracranial pressure (ICP). Maintaining cerebral perfusion pressure is critical in traumatic brain injury (TBI) to prevent secondary injury from ischemia. This specific elevation angle balances ICP reduction with maintenance of adequate cerebral blood flow. Normal ICP ranges from 5-15 mmHg in children. Choice B rationale A quiet, low-stimulus environment minimizes external stimuli that can trigger noxious responses and subsequently increase intracranial pressure (ICP) in a child with severe TBI. Sensory input processing requires cerebral energy and can exacerbate existing cerebral edema or injury. Reducing environmental stress supports cerebral metabolic rest and neuroprotection. Choice C rationale Monitoring for changes in the level of consciousness (LOC) is the most sensitive indicator of neurological status and potential deterioration in a TBI patient. A declining LOC, assessed using the Glasgow Coma Scale (GCS), can signal increasing intracranial pressure (ICP) or secondary brain injury. Prompt recognition allows for timely medical or surgical intervention to preserve neurological function. Choice D rationale Severe TBI increases the risk for post-traumatic seizures due to focal injury, cerebral edema, or hemorrhage disrupting normal cortical electrical activity. Seizure precautions, including padding side rails and ensuring airway safety, are mandatory to prevent injury and manage potential epileptic events. Prophylactic antiepileptic medications may also be initiated based on injury severity. Choice E rationale Administering D5W (dextrose 5% in water) as maintenance fluid is generally contraindicated in severe TBI. This hypotonic solution can rapidly shift free water into the injured, often edematous, brain tissue, potentially worsening cerebral edema and increasing intracranial pressure (ICP). Isotonic or hypertonic solutions are preferred to maintain euvolemia and serum osmolality.