Difficulty: Medium
Average Score: 91%
Full-length
A client with a history of increased intracranial pressure is admitted to the hospital for severe headaches. The client suddenly vomits and states, 'That's weird, I didn't even feel nauseated.' Which action should the nurse take next?
Correct answer
C
Rationale
Sudden vomiting without nausea in increased ICP suggests worsening pressure, requiring immediate RN notification (C). Documentation (A), lowering the bed (B), and antiemetics (D) are secondary.