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

Chronic head injuries can impair judgment, leading to non-compliance with care plans due to reduced awareness and impulse control. However, non-compliance alone is not a definitive behavioral characteristic of chronic head injury.

Choice B rationale

Rapid engagement in cognitively demanding tasks like chess within a week suggests intact neurological and cognitive function, which contradicts the expected deficits in chronic head injury patients.

Choice C rationale

Chronic head injuries commonly affect the frontal lobe, impairing executive functions such as planning, organizing, and controlling thoughts and behaviors. These deficits result from damage to neural pathways crucial for these cognitive tasks.

Choice D rationale

The ability to process multiple pieces of information simultaneously requires intact cognitive functioning, typically disrupted in chronic head injuries due to neuronal damage, particularly in the prefrontal cortex.

A. Approach the client from the unaffected side. B. Apply an eye patch to the affected eye. C. Teach exercises involving the eye muscles with full range of motion twice per day. D. Teach the client scanning techniques.

Correct Answer is D

Explanation

Choice A rationale

Approaching the client from the unaffected side does not stimulate compensation or adaptation. It limits the opportunity for neural adjustment and rehabilitation to optimize functional use of the affected side.

Choice B rationale

Eye patches may address double vision but are ineffective in enhancing sensory perception compensation for hemianopsia. Rehabilitation focuses on improving spatial awareness, not restricting visual fields.

Choice C rationale

Muscle exercises aid ocular health but do not scientifically compensate for hemianopsia. Scanning techniques provide more effective sensory perception rehabilitation in spatial deficits caused by this condition.

Choice D rationale

Scanning techniques teach clients to move their head or eyes consciously to view their entire surroundings. This method compensates for sensory deficits, helping clients adapt effectively during rehabilitation. .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

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?