What is the first step a nurse should take when caring for a client with a traumatic brain injury?

Monitoring for signs of increased intracranial pressure (ICP) is crucial in the initial management of a client with a traumatic brain injury. This is because a traumatic brain injury can lead to swelling or bleeding in the brain, which may elevate ICP, potentially leading to serious complications such as brain herniation or neurological deterioration.

Recognizing changes in the client's neurological status and monitoring vital signs can provide early indications of increased ICP. Signs might include changes in level of consciousness, headache, vomiting, or altered pupil response. By prioritizing this assessment, the nurse plays a vital role in detecting complications early and ensuring prompt interventions, which can significantly affect the client's prognosis and recovery.

While administering pain relief and ensuring comfort are important components of care, they should not take precedence over the immediate need to monitor ICP. Scheduling a CT scan is also an essential part of the diagnostic process, but it is secondary to the ongoing assessment of the client’s neurological status. Prioritizing the monitoring of ICP ensures that the most significant threat to the client’s well-being is addressed first.