A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

Elevate the client's head on two pillows

Decrease the noise level in the client's room

Suction the endotracheal tube frequently

Administer a stool softener

Give a 500cc NS fluid bolus

Answer and Explanation

Correct Answer : B,D,E

Choice A reason:

Elevating the client's head on two pillows is not a standardized method for managing intracranial pressure. Instead, elevating the head of the bed to 30 degrees is a more effective strategy to promote venous drainage and reduce ICP.

Choice B reason:

Decreasing the noise level in the client's room helps create a calm environment, which can reduce stress and prevent increases in ICP. Excessive noise and stimulation can elevate intracranial pressure.

Choice C reason:

Frequent suctioning of the endotracheal tube can actually increase ICP due to the stimulation and potential for causing a cough reflex. Suctioning should be performed only as necessary and with care.

Choice D reason:

Administering a stool softener helps prevent straining during bowel movements, which can increase ICP. Ensuring regular and comfortable bowel movements is crucial in managing intracranial pressure.

Choice E reason:

Giving a 500cc NS fluid bolus can be appropriate in some clinical scenarios to maintain adequate blood pressure and perfusion. However, fluid management must be carefully balanced to avoid fluid overload, which could increase ICP. Generally, fluid boluses are not the primary method for managing ICP.

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Correct Answer is C

Explanation

Choice A reason:

Lower levels of arterial carbon dioxide do not directly facilitate brain oxygenation. While maintaining appropriate CO2 levels is important for overall respiratory function, the primary reason for targeting a specific PaCO2 range in traumatic brain injury is related to intracranial pressure control.

Choice B reason:

Although carbon dioxide is indeed a waste product that must be eliminated from the body, this statement does not explain why specific PaCO2 levels are targeted in the context of traumatic brain injury. The primary concern is the impact of CO2 on intracranial pressure.

Choice C reason:

Carbon dioxide is a potent vasodilator, and elevated levels can lead to increased intracranial pressure (ICP). By maintaining PaCO2 within a range of 35-38 mmHg, the healthcare provider aims to prevent hypercapnia and the resulting vasodilation, which can exacerbate intracranial hypertension in patients with traumatic brain injury.

Choice D reason:

Lower levels of arterial carbon dioxide are not specifically essential for gas exchange. The primary concern with PaCO2 management in traumatic brain injury is controlling intracranial pressure, rather than optimizing gas exchange alone.

A. The spouse assists the client into a wheelchair and coaches deep coughing. B. The spouse assists the client into high-Fowler position and encourages taking a number of deep breaths. C. The spouse places hands on the client's lateral chest and pushes inward on exhalation. D. The spouse places hands below the client's diaphragm and pushes upward with exhalation.

Correct Answer is D

Explanation

Choice A reason:

While assisting the client into a wheelchair and coaching deep coughing can be beneficial, it does not specifically describe the technique for performing assistive coughing, which is crucial for a quadriplegic patient who cannot generate effective coughs on their own.

Choice B reason:

Placing the client in a high-Fowler position and encouraging deep breaths can be helpful in enhancing lung expansion and breathing, but it does not address the specific method of assistive coughing, which requires manual assistance to be effective.

Choice C reason:

Placing hands on the lateral chest and pushing inward on exhalation is not the correct technique for assistive coughing. This method may not generate sufficient force to help with airway clearance in a quadriplegic patient.

Choice D reason:

Placing hands below the client's diaphragm and pushing upward with exhalation is the correct technique for assistive coughing, also known as quad coughing. This method helps to increase the force of the cough, allowing for better clearance of secretions from the airway, which is essential for patients with quadriplegia.

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A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Why does the healthcare provider prescribe a ventilator setting to maintain partial pressure of arterial carbon dioxide (PaCO2) between 35 and 38 mmHg for a patient with traumatic brain injury?

Correct Answer is C

Explanation

Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

Correct Answer is D

Explanation

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