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

Clopidogrel is an antiplatelet agent that prevents platelet aggregation but does not affect arrhythmias. It reduces clot formation risk, which is critical for patients with a history of TIA or stroke.

Choice B rationale

Clopidogrel does not lower blood pressure. It works by inhibiting platelet aggregation to prevent thrombus formation, not addressing the mechanisms of hypertension or blood pressure control.

Choice C rationale

Clopidogrel does not directly affect peripheral artery disease symptoms, such as leg pain. It is used to reduce the risk of thrombotic events like strokes and heart attacks by preventing platelet aggregation.

Choice D rationale

Clopidogrel inhibits platelet aggregation by blocking the ADP receptor on platelets, reducing the risk of clot formation. This is crucial for preventing ischemic events in patients with a history of TIA.

A. Non-tender lymph nodes, productive cough. B. Chills, aches, flu-like symptoms. C. Abdominal cramping, loose stools. D. High fever, severe headache, change in mentation.

Correct Answer is B

Explanation

Choice A rationale

Non-tender lymph nodes and productive cough are more suggestive of later-stage infections or malignancies, not early HIV presentation which resembles acute viral syndrome.

Choice B rationale

Flu-like symptoms such as chills and aches occur during acute retroviral syndrome due to initial viral replication and immune response shortly after HIV infection.

Choice C rationale

Abdominal cramping and loose stools are associated with gastrointestinal infections in later stages of HIV due to opportunistic pathogens, not acute early-stage presentation.

Choice D rationale

High fever, severe headache, and change in mentation are indicative of central nervous system infections or complications in advanced HIV stages, not early acute HIV symptoms.

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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?