A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

The correct answer is: a. Place a black tag on the client’s upper body and attempt to help the next client in need.

Choice A: Place a black tag on the client’s upper body and attempt to help the next client in need.

In mass casualty incidents, the START (Simple Triage and Rapid Treatment) triage system is often used. According to this system, if a patient is apneic (not breathing) and does not resume breathing after repositioning the airway, they are considered deceased or non-salvageable and should be tagged with a black tag. This allows the nurse to focus on other victims who have a higher chance of survival.

Choice B: Start CPR

While starting CPR might seem appropriate in a normal setting, during a mass casualty incident, resources and time are limited. The priority is to save as many lives as possible. Performing CPR on an apneic patient with a weak pulse would take significant time and resources that could be used to help other victims with a higher chance of survival.

Choice C: Place a red tag on the client’s upper body and obtain immediate help from other personnel.

A red tag is used for patients who need immediate care and have a high chance of survival if treated promptly. Since the client remains apneic even after repositioning the airway, they do not meet the criteria for a red tag.

Choice D: Reposition the client’s upper airway a second time before assessing his respirations.

Repositioning the airway a second time is not recommended in the START triage system. If the patient does not resume breathing after the initial repositioning, they are considered non-salvageable.

Choice A: Provide a brightly lit environment is not an intervention that the nurse should take. A brightly lit environment can stimulate the brain and increase intracranial pressure. The nurse should provide a quiet and dimly lit environment to reduce sensory stimuli and promote rest.

Choice B: Elevate the head of the bed is an intervention that the nurse should take. Elevating the head of the bed to 30 degrees can help reduce intracranial pressure by facilitating venous drainage from the brain and decreasing cerebral blood volume. The nurse should avoid flexing or extending the neck, which can impede blood flow and increase intracranial pressure.

Choice C: Encourage a minimum intake of 2000 mL (67.6 oz) of clear fluids per day is not an intervention that the nurse should take. A high fluid intake can increase intracranial pressure by increasing blood volume and cerebral edema. The nurse should monitor fluid balance and restrict fluid intake as prescribed to maintain normal osmolality and prevent fluid overload.

Choice D: Teach controlled coughing and deep breathing is not an intervention that the nurse should take. Coughing and deep breathing can increase intrathoracic pressure, which can increase intracranial pressure by reducing venous return from the brain. The nurse should avoid activities that can increase intrathoracic pressure, such as straining, sneezing, or blowing the nose. The nurse should also administer oxygen as prescribed to maintain adequate oxygenation and perfusion of the brain.