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 D

Explanation

A. Hypotension is not typically associated with adrenal cortex hyperfunction; in fact, patients may experience hypertension due to excess cortisol and aldosterone.
B. Dehydration is more common with adrenal insufficiency than hyperfunction, as excess hormone production often leads to fluid retention.
C. Hyponatremia is generally not a concern with adrenal cortex hyperfunction; clients may experience hypernatremia instead due to fluid retention.
D. Hypokalemia is a significant risk in clients with adrenal cortex hyperfunction, especially due to the effects of excessive aldosterone, which promotes sodium retention and potassium excretion.

A. Diplopia B. Ataxia C. A change in the Glasgow Coma Scale score from 13 to 11 D. A decrease in heart rate from 76 to 69 bpm

Correct Answer is C

Explanation

A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.

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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

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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