A client with a brain tumor is complaining of a headache upon awakening. Which nursing action would the nurse take first?
A) Elevate the head of the bed.
B) Complete a head-to-toe assessment.
C) Administer morning dose of anticonvulsant.
D) Administer Percocet as ordered.
A
Feedback:
The first action would be to elevate the head of the bed to promote venous drainage of blood and CSF. Then, a neurological assessment would be completed to determine if any other assessment findings are significant of increasing ICP. The administering of routine ordered drugs is not a priority, and narcotic analgesics would be avoided in clients with ICP issues.
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