MEDizzy - The intensive care nurse is caring for a client diagnosed

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Head Injury

The intensive care nurse is caring for a client diagnosed with a TBI who is exhibiting decorticate posturing. Three hours later the client has flaccid posturing. Which action should the nurse implement first?

ExplanationFlaccid posturing is the worst-case scenario for a client with a TBI; therefore, the nurse should notify the HCP. Completing a neurological assessment, administering an osmotic diuretic, and reassessing the client are all plausible interventions, but they are not the first to be implemented.