A client who had a brain attack was admitted to the intensive care unit yesterday. The nurse observes that the client is becoming lethargic and is unable to articulate words when speaking. What does the nurse do next?
a. Check the client's blood pressure and apical heart rate.
b. Elevate the back rest to 30 degrees and notify the health care provider.
c. Place the client in a supine position with a flat back rest, and observe.
d. Assess the client's white blood cell count and differential.
B
The client is experiencing signs of increased intracranial pressure (ICP). Raising the head of the bed would help decrease ICP. The health care provider should then be notified immediately so that other interventions to reduce ICP can be instituted. Assessing vital signs and white blood cell count is not the priority at this time.
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