A nurse is caring for a client who has a head injury. The client states they fell off a ladder while painting approximately 2 hours ago and lost consciousness for 45 minutes according to their partner. The nurse should determine that the client is experiencing which of the following classifications of traumatic brain injury?

Choice A reason: Hypotension is not a common manifestation of ARF. Hypotension is a low blood pressure, defined as less than 90/60 mm Hg. Hypotension can have many causes, such as dehydration, blood loss, heart problems, or medications. ARF does not directly cause hypotension, but it can lead to complications such as shock or organ failure, which can lower the blood pressure.

Choice B reason: Decreased level of consciousness is a frequent manifestation of ARF. Decreased level of consciousness is a state of impaired awareness, orientation, memory, or judgment. Decreased level of consciousness can occur in ARF due to several factors, such as hypoxia, hypercapnia, acidosis, or infection. The nurse should monitor the mental status of the client with ARF and report any changes to the provider.

Choice C reason: Severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective sensation of difficulty breathing or shortness of breath. Severe dyspnea can occur in ARF due to the reduced oxygen delivery or increased carbon dioxide retention in the blood. The nurse should assess the respiratory rate, rhythm, depth, and effort of the client with ARF and provide oxygen therapy as prescribed.

Choice D reason: Headache is not a typical manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can have many causes, such as stress, dehydration, sinusitis, or migraine. ARF does not directly cause headache, but it can cause increased intracranial pressure or cerebral edema, which can trigger headache.

Choice E reason: Nausea is not a usual manifestation of ARF. Nausea is a feeling of sickness or discomfort in the stomach that can lead to vomiting. Nausea can have many causes, such as food poisoning, motion sickness, pregnancy, or medications. ARF does not directly cause nausea, but it can cause gastrointestinal bleeding or hepatic encephalopathy, which can induce nausea.

Choice A reason: Using log rolling to reposition the client is not advisable for a client who has increased ICP. Log rolling is a technique that involves moving the client as a unit, without flexing the spine, to prevent spinal cord injury. However, log rolling can also increase ICP by reducing venous drainage from the head and increasing cerebral blood volume. Therefore, the nurse should avoid log rolling the client unless there is a suspected spinal injury.

Choice B reason: Instructing the client to cough and breathe deep is not appropriate for a client who has increased ICP. Coughing and deep breathing can increase intrathoracic pressure, which can reduce venous return to the heart and increase ICP. Additionally, coughing and deep breathing can cause hyperventilation, which can lower the partial pressure of carbon dioxide in the blood and cause cerebral vasoconstriction. This can reduce cerebral perfusion and oxygen delivery to the brain.

Choice C reason: Placing a warming blanket on the client is not recommended for a client who has increased ICP. A warming blanket can increase the body temperature, which can increase the metabolic rate and oxygen demand of the brain. This can worsen cerebral ischemia and edema. Moreover, a warming blanket can cause vasodilation, which can increase cerebral blood volume and ICP. Therefore, the nurse should maintain a normal body temperature for the client and avoid hyperthermia.

Choice D reason: Placing the client in a supine position is the best action for the nurse to take for a client who has increased ICP. The supine position is a way of lying on a table with the back, face, and abdomen facing upwards. It is used for various surgeries and examinations, such as cranial, cardiac, abdominal, and thoracic surgery. It can also prevent respiratory, skin, and circulatory problems. The supine position can help lower ICP by facilitating venous drainage from the head and reducing cerebral blood volume [^10^]. However, the nurse should also elevate the head of the bed to 30 degrees to optimize cerebral perfusion pressure and avoid neck flexion or rotation, which can impair venous drainage.