A nurse is caring a client who has a traumatic brain injury and is experiencing increased intracranial pressure. Which of the following actions should the nurse take to decrease the intracranial pressure?

Maintain the head of the client's bed at a 10° angle.

Suction the client's airway every hour.

Reposition the client by using the log rolling technique.

Use a pillow to flex the client's neck.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Maintain the head of the client's bed at a 10° angle: A 10° angle is too low to effectively promote venous drainage from the brain. To reduce intracranial pressure (ICP), the head of the bed should generally be elevated to 30–45° to improve cerebral venous outflow.

B. Suction the client's airway every hour: Frequent suctioning increases intrathoracic pressure and can stimulate the vagus nerve, both of which may raise ICP. Suctioning should be done only when clinically indicated and using minimal duration and pressure.

C. Reposition the client by using the log rolling technique: Log rolling maintains spinal alignment and minimizes abrupt head or neck movement, which can increase ICP. This technique is especially important in patients with brain or spinal injuries to prevent sudden shifts in pressure.

D. Use a pillow to flex the client's neck: Neck flexion can obstruct jugular venous outflow, leading to increased ICP. The head and neck should remain in a neutral, midline position to facilitate venous drainage from the brain.

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Correct Answer is A

Explanation

Rationale:

A. Photophobia: Sensitivity to light is a common neurological symptom in meningitis. Inflammation of the meninges irritates the cranial nerves, particularly those involved in eye movement and vision, making light exposure painful and triggering discomfort or headaches.

B. Negative Brudzinski's sign: A positive Brudzinski’s sign is expected in meningitis. It occurs when neck flexion causes involuntary hip and knee flexion due to meningeal irritation. A negative sign would not support the diagnosis and is not an expected finding.

C. Excessive perspiration: While fever is a common manifestation of meningitis, excessive sweating is not a typical or defining feature of the disease. Autonomic changes may occur but are not reliable diagnostic indicators.

D. Bradycardia: Meningitis more commonly presents with tachycardia due to fever and systemic infection. Bradycardia is not typical unless there is increased intracranial pressure affecting brainstem function, which would be seen in more advanced or complicated cases.

A. Position the client to maintain hip flexion. B. Administer an enema if the client develops constipation. C. Provide 100% oxygen to the client prior to suctioning. D. Ensure that the PEEP level is set at 20 cm of H2O.

Correct Answer is C

Explanation

Rationale:

A. Position the client to maintain hip flexion: Hip flexion greater than 90 degrees increases intra-abdominal and intrathoracic pressure, which can impair venous return from the brain and raise intracranial pressure. The hips should be kept in a neutral, extended position.

B. Administer an enema if the client develops constipation: While managing constipation is important, enemas can stimulate the vagus nerve and raise ICP due to straining. Stool softeners or gentle interventions are preferred to avoid abrupt increases in intracranial pressure.

C. Provide 100% oxygen to the client prior to suctioning: Preoxygenation prevents hypoxia, which can increase cerebral blood flow and elevate ICP. Suctioning should always be preceded by hyperoxygenation to reduce this risk in patients with brain injuries.

D. Ensure that the PEEP level is set at 20 cm of H2O: High PEEP levels like 20 cm H₂O can impede cerebral venous outflow and raise ICP. PEEP should be used cautiously in clients with brain injuries and adjusted to the lowest effective setting to maintain oxygenation.

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A nurse is caring a client who has a traumatic brain injury and is experiencing increased intracranial pressure. Which of the following actions should the nurse take to decrease the intracranial pressure?

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