A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?
Flex the client's neck forward.
Group several nursing activities to be completed at one time.
Limit suctioning the client's airway to 30 seconds at a time.
Place the client in a quiet environment.
The Correct Answer is D
A. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.
B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate. Therefore, this choice is incorrect.
C. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.
D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
"You should administer the medication at bedtime." This statement is incorrect option. Administering methylphenidate at bedtime is not appropriate because it is a stimulant medication, and taking it in the evening could interfere with the child's ability to fall asleep and disrupt their sleep pattern.
"Your child should avoid foods containing tyramine. “This statement is incorrect option. Tyramine is not a concern with methylphenidate. Tyramine is associated with certain antidepressant medications, such as MAO inhibitors. Methylphenidate is not a MAO inhibitor, so there is no need for the child to avoid tyramine-containing foods.
Option C: "You should administer the medication after breakfast." This is the correct option. Administering methylphenidate after breakfast is a common practice because it allows the child to benefit from the medication during school hours when improved attention and focus are needed the most.
"Your child should avoid excess sodium intake." This statement is an incorrect option. Excess sodium intake is not directly related to methylphenidate use. However, it is generally a good idea for anyone, including children, to have a balanced and healthy diet, which may include monitoring sodium intake. But it is not specifically tied to the administration of methylphenidate.
Correct Answer is B
Explanation
A. Incorrect. The nurse should check the functioning of oxygen equipment daily, not weekly, to ensure safety and proper delivery of oxygen.
B. Correct. The nurse should instruct the client to wear clothing made with cotton fabrics while oxygen is in use, as synthetic fabrics can generate static electricity and cause sparks that could ignite the oxygen.
C. Incorrect. The nurse should instruct the client to avoid petroleum-based lubricants, such as Vaseline, as they are flammable and could cause burns if exposed to oxygen. The nurse should recommend water-soluble lubricants, such as K-Y jelly, instead.
D. Incorrect. The nurse should instruct the client to store full oxygen tanks upright, not on their side, to prevent them from rolling and damaging the valve or regulator.
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