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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Contacting the facility chaplain to visit with the client may be helpful for some clients who have spiritual needs or concerns, but it does not address the client's expressed desire to go home. The nurse should respect the client's wishes and preferences and not impose their own beliefs or values on them.

B. Explaining the process of leaving the facility against medical advice may discourage the client from pursuing their goal of going home and imply that they are making a wrong decision. The nurse should not judge or coerce the client, but rather provide them with information and support to make an informed choice.

C. Making a referral for social services is the best action for the nurse to take, as it will help the client access resources and services that can facilitate their discharge planning and home care arrangements. The social worker can also assist with financial, legal, or emotional issues that may arise from the terminal diagnosis.

D. Encouraging the client to continue with inpatient care may go against the client's wishes and values, and may cause them more distress and suffering. The nurse should respect the client's autonomy and dignity and support their quality of life goals.

A. The frequency in which the client presses the call button B. The client's most recent ventilator settings C. The time of the client's last dose of pain medication D. The last time the provider evaluated the client

Correct Answer is C

Explanation

A. The frequency in which the client presses the call button is not a priority for the change-of-shift report, as it does not indicate the level of pain or comfort of the client. This choice is incorrect.

B. The client's most recent ventilator settings are not applicable, as the client was weaned from mechanical ventilation and no longer requires it. This choice is incorrect.

C. The time of the client's last dose of pain medication is important for the change-of-shift report, as it helps to ensure continuity of care and prevent under- or over-medication of the client. This choice is correct.

D. The last time the provider evaluated the client is not relevant for the change-of-shift report, as it does not reflect the current status of the client. This choice is incorrect.

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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)?

Nursing Test Bank

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