A nurse is caring for a patient with a head injury and increased intracranial pressure (ICP). Which of the following interventions should the nurse implement to help prevent an increase in ICP?

Keep the patient in a low flat position to improve perfusion to the brain.

Allow the patient to move around in bed to prevent muscle stiffness.

Administer sedatives as ordered to reduce agitation and prevent straining

Encourage the patient to cough and sneeze to clear respiratory secretions.

Answer and Explanation

The Correct Answer is C

A. Keep the patient in a low flat position to improve perfusion to the brain: Positioning the patient flat can increase intracranial pressure by reducing venous drainage from the brain. The head of the bed is typically elevated 30 degrees to facilitate venous return and maintain cerebral perfusion without increasing ICP.

B. Allow the patient to move around in bed to prevent muscle stiffness: Uncontrolled movement or frequent repositioning can increase ICP by stimulating the patient and causing straining or Valsalva maneuvers. Careful, minimal movement is preferred to prevent spikes in intracranial pressure while still addressing the need for mobility safely.

C. Administer sedatives as ordered to reduce agitation and prevent straining: Sedatives help reduce agitation, anxiety, and pain, which can elevate ICP through increased sympathetic stimulation and physical straining. Controlled sedation facilitates patient comfort, minimizes metabolic demands, and helps maintain ICP within safe limits.

D. Encourage the patient to cough and sneeze to clear respiratory secretions: Coughing and sneezing increase intrathoracic pressure, which impedes venous return from the brain and temporarily raises ICP. These activities should be minimized or performed cautiously with support to avoid abrupt increases in intracranial pressure.

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Correct Answer is B

Explanation

A. Continue heparin therapy and monitor platelet counts: Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse reaction in which antibodies form against the heparin–platelet factor 4 complex, leading to platelet activation and thrombosis. Continuing heparin can worsen platelet consumption and increase the risk of life-threatening thromboembolic events.

B. Discontinue heparin immediately and start an alternative anticoagulant: The priority intervention in suspected HIT is the immediate cessation of all heparin products to prevent further antibody-mediated platelet activation. Because HIT creates a prothrombotic state, an alternative non-heparin anticoagulant is initiated to reduce the risk of DVT or PE.

C. Administer platelet transfusion to manage thrombocytopenia: In HIT, thrombocytopenia results from platelet activation and consumption, not from decreased production. Transfusing platelets may exacerbate thrombosis by providing additional substrate for clot formation. Platelet transfusions are generally avoided unless there is significant active bleeding.

D. Administer intravenous fluids to prevent dehydration: While maintaining adequate hydration is important for overall circulatory stability, IV fluids do not address the immune-mediated platelet activation or thrombotic risk associated with HIT. The immediate threat is thrombosis, which requires stopping heparin and initiating alternative anticoagulation.

A. Providing oral fluids B. Stopping the burning process C. Covering with warm blankets D. Giving morphine

Correct Answer is B

Explanation

A. Providing oral fluids: While fluid replacement is important in burn victims, oral intake in the prehospital setting may be limited by airway compromise, nausea, or altered consciousness. Immediate fluid resuscitation is often deferred until intravenous access is established in a controlled setting.

B. Stopping the burning process: The priority in prehospital burn care is to halt the source of injury to prevent further tissue damage. This may involve extinguishing flames, removing the patient from hot surfaces, or chemical decontamination. Controlling the burn source directly limits injury progression and is the first and most critical intervention.

C. Covering with warm blankets: Covering the patient helps prevent hypothermia, which is a significant concern in extensive burns, but it is a secondary action after ensuring the burn source is eliminated. Warm blankets support stabilization but do not stop ongoing tissue damage.

D. Giving morphine: Pain management is essential, but analgesics do not prevent further injury. Administering morphine is secondary to stopping the burn source, securing the airway, and stabilizing the patient. Pain control is provided once the patient is safe from ongoing harm.

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A nurse is caring for a patient with a head injury and increased intracranial pressure (ICP). Which of the following interventions should the nurse implement to help prevent an increase in ICP?

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