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

• A. Perform the exercises less frequently
• B. Use restraints to protect the patient from injury
• C. Continue the exercises to maintain musculoskeletal function
• D. Administer CNS depressants to lightly sedate the patient

Answer: (A)

Managing stimulation is key when ICP is elevated. Severe decerebrate posturing signals that the brain is highly irritable or injured and may not tolerate additional stimuli. Passive range-of-motion exercises act as a stimulus that can increase sympathetic activity and cerebral metabolic demand, which in turn raises cerebral blood flow and ICP. When this kind of posturing appears during ROM, the safest move is to reduce or pause the activity to prevent further ICP elevation and potential complications. Restraints are not an appropriate solution and can worsen outcomes by increasing agitation and pressure. Sedation might be used to limit agitation and metabolic demand, but the immediate priority is to minimize stimulation by performing ROM less frequently and continuing close neurologic monitoring.