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 brain is at risk for increased intracranial pressure from bleeding and edema, so the priority is to optimize cerebral venous drainage. Elevating the head of the bed to about 30 degrees helps blood and CSF drain away from the brain, reducing intracranial pressure while keeping the head in a midline position to avoid venous obstruction. This simple position change is a continuous, nurse-driven action to implement during the transfer to the medical unit.

Osmotic diuretics require a physician order and IV access and are not an immediate nursing action during transfer. A neurological assessment is essential and ongoing, but the initial intervention to address ICP is maintaining the head-elevated position. A stool softener may help prevent straining, which can raise ICP, but it is not the primary intervention to implement first in this scenario.