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 ["A","B","C","D","E","F"]
Explanation
A. This is a correct action. Firmly massaging the uterine fundus can help contract the uterus and reduce bleeding by expelling clots and compressing blood vessels.
B. This is a correct action. Providing emotional support can help calm the client and reduce anxiety, which can worsen bleeding by increasing heart rate and blood pressure.
C. This is a correct action. Administering oxygen can help improve tissue perfusion and oxygenation, which can prevent hypoxia and shock due to blood loss.
D. This is a correct action. Weighing the perineal pads can help estimate the amount of blood loss and monitor the effectiveness of interventions to control bleeding.
E. This is a correct action. Inserting an indwelling urinary catheter can help empty the bladder and prevent it from displacing or compressing the uterus, which can interfere with uterine contraction and increase bleeding.
F. This is a correct action. Administering methylergonovine can help stimulate uterine contraction and reduce bleeding by constricting blood vessels in the uterus.
Correct Answer is A
Explanation
A is correct because aPTT (activated partial thromboplastin time) measures the effectiveness of heparin therapy and guides dosage adjustments.
B is incorrect because PT (prothrombin time) measures the effectiveness of warfarin therapy, not heparin.
C is incorrect because INR (international normalized ratio) is a standardized version of PT that also monitors warfarin therapy, not heparin.
D is incorrect because WBC count (white blood cell count) measures the body's immune response and has no relation to heparin therapy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.