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 D

Explanation

Choice A rationale

Hypertension is not the primary concern in cervical spinal cord injuries at C-3, where respiratory compromise due to diaphragm paralysis is the leading cause of complications or mortality.

Choice B rationale

Bradycardia can occur due to vagal stimulation in spinal injuries but is less life-threatening compared to the respiratory compromise caused by diaphragmatic paralysis.

Choice C rationale

Sepsis may develop in spinal cord injury patients, particularly from infections like pneumonia or urinary tract infections, but respiratory failure is the most acute concern at C-3.

Choice D rationale

Respiratory compromise occurs due to impaired diaphragm function at C-3, making it the primary cause of morbidity or mortality, necessitating prompt respiratory support and monitoring.

Correct Answer is ["2525"]

Explanation

Step 1 is calculate intake from lactated Ringer’s: 150 mL/hr × 9 hrs = 1350 mL.

Step 2 is calculate cefazolin intake: 100 mL × 1 dose = 100 mL.

Step 3 is calculate intake from two units of packed RBCs: 275 mL + 250 mL = 525 mL.

Step 4 is calculate intake from two IV boluses: 250 mL × 2 = 500 mL.

Step 5 is calculate intake from ranitidine infusion: 50 mL × 1 dose = 50 mL.

Step 6 is calculate total intake: 1350 mL + 100 mL + 525 mL + 500 mL + 50 mL = 2525 mL. Final calculated intake is 2525 mL.

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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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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in the acute care setting with a spinal cord injury at the level of C-3. The nurse understands that the main cause of complications or death related to this injury includes:

Correct Answer is D

Explanation

Correct Answer is ["2525"]

Explanation

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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?