During range-of-motion exercises for an unconscious patient with increased ICP, the patient develops severe decerebrate posturing. What should the nurse do first?

• A. Use restraints to protect the patient from injury.
• B. Continue the exercises because they are necessary to maintain musculoskeletal function.
• C. Administer central nervous system (CNS) depressants to lightly sedate the patient.
• D. Perform the exercises less frequently because posturing can increase ICP.

Answer: (D)

When ICP is elevated, anything that stimulates the body or increases venous return can raise ICP further. Severe decerebrate posturing during range-of-motion moves signals brainstem involvement and a dangerous rise in ICP. The first step is to reduce the stimulus to the brain, so performing the exercises less frequently helps limit ICP spikes and gives time to reassess the patient’s neurologic status and response.

Beyond that, stop the activity if posturing recurs and notify the clinician, while continuing to follow ICP precautions (head elevation, airway protection, avoid agitation, minimize coughing, monitor oxygenation). Restraints are not a routine protective measure, continuing ROM at same intensity isn’t safe, and giving CNS depressants isn’t a first‑line action without a clinician’s guidance.