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A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the ...

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A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the ...

A nurse is starting an intravenous line in a patient being treated for a head injury. Suddenly the patient extends his legs and demonstrates extreme plantar flexion. What action should be taken by the nurse?
1. Document the presence of decorticate posturing.
2. Immediately stop the attempt at intravenous insertion and obtain a blood pressure reading.
3. Assess the position of the patient’s arms.
4. Administer intravenous sedation as quickly as possible after access is obtained.

Textbook

High-Acuity Nursing

Edition: 6^th

Authors: Wagner, Hardin-Pierce

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Brilliant ツ

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