A nurse is caring for a client who is demonstrating signs of increasing intracranial pressure (ICP). The nurse recognizes that which nursing actions are indicated to decrease ICP?

Elevate the head of the bed to 30-45 degrees.

Administer intravenous fluids rapidly to increase intravascular volume.

Keep the client in a calm and quiet environment.

Administer morphine sulfate as prescribed for pain relief.

Allow the client to perform Valsalva maneuver.

Answer and Explanation

Correct Answer : A,C,D

A. Elevating the head of the bed to 30-45 degrees helps facilitate venous drainage from the brain, thereby reducing ICP.
B. Administering intravenous fluids rapidly is not appropriate, as it can lead to fluid overload and increase ICP.
C. Keeping the client in a calm and quiet environment minimizes stimulation, which can contribute to increased ICP.
D. Administering morphine sulfate as prescribed can provide pain relief, which may help decrease ICP since pain can contribute to increased intracranial pressure.
E. The Valsalva maneuver increases intrathoracic pressure and can lead to increased ICP, making it contraindicated in this scenario.

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Correct Answer is B

Explanation

A. While hormones from the adrenal cortex do influence various metabolic processes, mineralocorticoids primarily focus on fluid and electrolyte balance rather than having major effects on all organs' metabolism.
B. Mineralocorticoids, such as aldosterone, play a crucial role in regulating fluid and electrolyte balance by promoting sodium retention and potassium excretion in the kidneys.
C. Regulation of carbohydrate and protein metabolism is mainly the function of glucocorticoids, not mineralocorticoids.
D. The release of ACTH is regulated by corticotropin-releasing hormone (CRH) from the hypothalamus, not directly influenced by mineralocorticoids.

A. "The medication causes the pupil to constrict and will lower the pressure in the eye." B. "The medication will help dilate the eye to prevent pressure from occurring." C. "The medication will relax the muscles of the eyes and prevent blurred vision." D. "The medication will help block the responses that are sent to the muscles in the eye."

Correct Answer is A

Explanation

A. Miotic medications work by constricting the pupil, which opens the trabecular meshwork and facilitates the drainage of aqueous humor, thus lowering intraocular pressure in clients with glaucoma.
B. Miotics do not dilate the pupil; they constrict it. Dilation would actually increase intraocular pressure, which is not therapeutic in glaucoma.
C. While these medications do affect eye muscles, they do not specifically prevent blurred vision; their primary effect is on eye pressure.
D. Miotics do not block nerve responses; they work by direct action on the eye muscles to promote fluid drainage and reduce pressure.

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A nurse is caring for a client who is demonstrating signs of increasing intracranial pressure (ICP). The nurse recognizes that which nursing actions are indicated to decrease ICP?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing education regarding the adrenal cortex production of mineralocorticoids. The nurse should include that mineralocorticoids influence which of the following?

Correct Answer is B

Explanation

The nurse is providing teaching on the miotic medication the client has been prescribed for glaucoma. The client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?

Correct Answer is A

Explanation

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