A nurse is caring for a client who has a closed-head injury with elevated ICP readings ranging from 16 to 22 mm Hg. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP?
Elevate the client's head on two pillows.
Keep the client well hydrated.
Decrease the noise level in the client's room.
Suction the endotracheal tube frequently.
The Correct Answer is C
Choice A Reason:
Elevating the client's head on two pillows can help reduce ICP by promoting venous drainage from the brain. However, it is important to ensure that the head is not elevated too high, as this can impede venous return and potentially increase ICP. The recommended elevation is typically 30 degrees. While this intervention is beneficial, it is not the most critical action compared to reducing environmental stimuli.
Choice B Reason:
Keeping the client well hydrated is essential for overall health, but excessive hydration can increase ICP by increasing the volume of cerebrospinal fluid and blood within the cranial vault. Fluid management must be carefully monitored to avoid exacerbating ICP. Therefore, while hydration is important, it must be balanced and not excessive.
Choice C Reason:
Decreasing the noise level in the client's room is crucial for minimizing external stimuli that can increase ICP. Noise and other environmental stressors can lead to increased agitation and stress, which in turn can elevate ICP. Creating a calm and quiet environment helps in maintaining a stable ICP and is a non-invasive, easily implementable intervention.
Choice D Reason:
Frequent suctioning of the endotracheal tube can cause transient increases in ICP due to the stimulation and potential for coughing. While suctioning is necessary to maintain airway patency, it should be performed judiciously and only when clinically indicated. Over-suctioning can lead to spikes in ICP and should be avoided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Reduced blood pressure is not a specific complication of infective endocarditis. While hypotension can occur in severe cases due to septic shock, it is not a hallmark of the disease. Infective endocarditis primarily affects the heart valves and can lead to embolic events, heart failure, and other complications.
Choice B Reason:
Osler's nodes are a classic sign of infective endocarditis. These are painful, red or purple, raised lesions found on the hands and feet. They are caused by immune complex deposition and are indicative of the systemic nature of the infection. Their presence can help in the clinical diagnosis of infective endocarditis.
Choice C Reason:
Clear lung sounds are not a complication of infective endocarditis. In fact, clear lung sounds would generally indicate that there is no pulmonary involvement or congestion. Complications of infective endocarditis are more likely to involve the heart, kidneys, and other organs through embolic events.
Choice D Reason:
Increased appetite is not associated with infective endocarditis. Patients with this condition often experience symptoms such as fever, fatigue, and weight loss due to the chronic infection. Increased appetite would be an unusual finding and not related to the disease process.
Correct Answer is C
Explanation
Choice A Reason:
Suctioning the nose is not the first action to take. Suctioning can increase intracranial pressure and potentially cause further injury. It is important to first determine the nature of the drainage before taking any invasive actions.
Choice B Reason:
Notifying the physician is important, but it should be done after confirming the nature of the drainage. Testing the fluid for glucose can help determine if it is cerebrospinal fluid (CSF), which would indicate a serious complication requiring immediate medical attention.
Choice C Reason:
Testing the drainage for glucose is the correct first action. CSF contains glucose, so a positive test would confirm that the clear fluid is CSF. This is a critical step in diagnosing a CSF leak, which can occur with basal skull fractures and requires prompt intervention to prevent infection and other complications.
Choice D Reason:
Asking the client to blow their nose is contraindicated. Blowing the nose can increase intracranial pressure and exacerbate a CSF leak. It is important to avoid any actions that could worsen the condition until the nature of the drainage is confirmed.
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