A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.
What is the priority action by the nurse?

Continue with assessment and document findings.

Suction the patient to minimize secretions.

Notify the physician and raise the head of the bed 35–45 degrees.

Lower the head of the bed and pad the side rails.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.

Choice B rationale

Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.

Choice C rationale

Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.

Choice D rationale

Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.

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Correct Answer is C

Explanation

Choice A rationale

Soft restraints are utilized for agitation but are not prioritized in epilepsy care. Emergency equipment like suction ensures airway safety during seizures.

Choice B rationale

Glasgow Coma Scale evaluates neurological function but is less relevant for epilepsy management compared to essential tools like suction equipment for airway protection.

Choice C rationale

Suction equipment and oxygen are vital in epilepsy management to clear secretions and maintain oxygenation during seizures. Patent IV access allows rapid administration of emergency medications.

Choice D rationale

Dextrose infusion is used to treat hypoglycemia rather than seizures. Epilepsy care prioritizes tools like suction and oxygen for immediate seizure-related complications. .

A. Sharp, stabbing acute pain in the affected eye. B. Total loss of vision. C. A curtain-like loss of vision in the affected eye. D. Yellow discoloration of the sclera.

Correct Answer is C

Explanation

Choice A rationale

Detached retina typically does not present with sharp, stabbing pain. Instead, patients experience painless symptoms like vision abnormalities due to separation of the retina from supporting tissue.

Choice B rationale

Total vision loss is rare with a detached retina unless extensive damage occurs. Partial visual disruption, such as curtain-like vision loss, is a hallmark symptom.

Choice C rationale

A curtain-like loss of vision arises from retinal detachment, disrupting visual fields as the retina separates from its vascular supply and neural connections.

Choice D rationale

Yellow sclera discoloration is associated with jaundice due to bilirubin accumulation, unrelated to retinal detachment pathology, which affects visual symptoms and not scleral appearance.

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A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.What is the priority action by the nurse?

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A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.
What is the priority action by the nurse?