187. A patient with severe traumatic brain injury has an ICP of 20 mmHg. The nurse observes the patient is becoming increasingly agitated. What is the critical nursing action?
A.
Increase environmental stimulation
B.
Assess for pain, discomfort, or other causes of agitation, and administer analgesia/sedation as ordered to prevent further ICP elevation
✓
C.
Apply physical restraints immediately
D.
Administer a diuretic
📖 Additional Information
Increase environmental stimulation
Assess for pain, discomfort, or other causes of agitation, and administer analgesia/sedation as ordered to prevent further ICP elevation
