A client diagnosed with a hemorrhagic stroke is being transferred from the ICU to the medical unit. Which nursing intervention should the nurse initially implement?

A client diagnosed with a hemorrhagic stroke is being transferred from the ICU to the medical unit. Which nursing intervention should the nurse initially implement?

• A. Administer an osmotic diuretic.
• B. Complete a neurological assessment.
• C. Maintain the head of the bed at 30 degrees.
• D. Instruct the client to take a stool softener daily.

Answer: (C)

In hemorrhagic stroke, the top nursing priority is preventing a rise in intracranial pressure and maintaining adequate cerebral perfusion. Elevating the head of the bed to about 30 degrees helps by promoting venous drainage from the brain, which lowers intracranial pressure, while keeping the neck in a neutral position to avoid venous outflow obstruction. This simple, immediate action supports brain perfusion without requiring orders. Other actions, like giving an osmotic diuretic, require physician orders and are not something the nurse initiates on transfer. Completing a neurological assessment is essential for tracking status, but it doesn’t directly reduce intracranial pressure as rapidly as proper positioning. A stool softener helps prevent straining, which is beneficial, but it does not address the acute management of ICP during the transfer.

In hemorrhagic stroke, the top nursing priority is preventing a rise in intracranial pressure and maintaining adequate cerebral perfusion. Elevating the head of the bed to about 30 degrees helps by promoting venous drainage from the brain, which lowers intracranial pressure, while keeping the neck in a neutral position to avoid venous outflow obstruction. This simple, immediate action supports brain perfusion without requiring orders.

Other actions, like giving an osmotic diuretic, require physician orders and are not something the nurse initiates on transfer. Completing a neurological assessment is essential for tracking status, but it doesn’t directly reduce intracranial pressure as rapidly as proper positioning. A stool softener helps prevent straining, which is beneficial, but it does not address the acute management of ICP during the transfer.