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.

Answer and Explanation

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.

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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.

A. Establish IV access and start fluid replacement. B. Insert nasogastric tube. C. Keep neck stabilized. D. Monitor pulse and blood pressure frequently.

Correct Answer is C

Explanation

Choice A Reason:
Establishing IV access and starting fluid replacement is important for maintaining hemodynamic stability, especially if there is significant blood loss. However, it is not the immediate priority in this scenario. Ensuring the neck is stabilized takes precedence to prevent potential spinal cord injury.

Choice B Reason:
Inserting a nasogastric tube is not a priority in the acute management of a trauma patient with a head injury. This procedure can be deferred until the patient's airway and cervical spine are secured and other life-threatening conditions are addressed.

Choice C Reason:
Keeping the neck stabilized is the priority action. In a trauma patient with a head injury, there is a high risk of cervical spine injury. Stabilizing the neck prevents further damage to the spinal cord, which could result in paralysis or other severe complications.

Choice D Reason:
Monitoring pulse and blood pressure frequently is essential for assessing the patient's hemodynamic status. However, it is not the immediate priority over stabilizing the cervical spine. Once the neck is stabilized, continuous monitoring of vital signs should follow.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is a complicated manifestation of infective endocarditis?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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