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. Hormone replacement is generally used to supplement deficiencies rather than inhibit excess hormone release.
B. Dopamine agonists, such as bromocriptine, are used to inhibit the release of growth hormone from the anterior pituitary, which is beneficial in treating acromegaly, a condition caused by excess growth hormone.
C. Levothyroxine is a thyroid hormone replacement and is not effective in controlling pituitary hormone release.
D. Corticosteroids do not inhibit growth hormone release and are typically used to manage inflammation rather than for pituitary hormone control.

A. Turn the client onto their operative side. B. Administer the prescribed pain medication and antiemetic. C. Call the surgeon. D. Reassure the client that this is normal.

Correct Answer is B

Explanation

A. Turning the client onto their operative side could increase pressure on the eye and is not an appropriate first action.
B. Administering prescribed pain medication and antiemetic is essential to address the client's severe pain and nausea, which are priority concerns in the postoperative period.
C. While it may be necessary to notify the surgeon if symptoms persist, the immediate priority is to alleviate the client's discomfort.
D. Reassuring the client that these symptoms are normal is misleading; severe pain and nausea postoperatively should be addressed promptly.

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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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