A nurse is caring for a patient with increased intracranial pressure (ICP). The patient's most recent ICP reading is 22 mmHg. Which of the following actions should the nurse take immediately?

Increase the patient's head of bed to 30 degrees.

Administer an osmotic diuretic as ordered

Administer high-dose corticosteroids to reduce brain swelling.

Administer pain medications to relieve discomfort.

Answer and Explanation

The Correct Answer is B

A. Increase the patient's head of bed to 30 degrees: Elevating the head of the bed is a standard measure to promote venous drainage and help prevent further increases in ICP. However, this intervention is preventive and supportive and may not provide immediate reduction in ICP once it has acutely risen to 22 mmHg.

B. Administer an osmotic diuretic as ordered: Osmotic diuretics, such as mannitol, draw fluid from brain tissue into the intravascular space, rapidly reducing cerebral edema and lowering ICP. Immediate administration is critical when ICP exceeds normal limits (typically >20 mmHg) to prevent secondary brain injury from decreased cerebral perfusion and herniation.

C. Administer high-dose corticosteroids to reduce brain swelling: Corticosteroids are not routinely indicated for ICP management in acute traumatic brain injury; they are primarily used in vasogenic edema associated with brain tumors or specific inflammatory conditions. They do not act rapidly enough to address acute elevations in ICP.

D. Administer pain medications to relieve discomfort: While pain control is important to prevent sympathetic stimulation that can elevate ICP, analgesics alone do not rapidly lower ICP. Immediate reduction of dangerously high ICP requires interventions that directly decrease cerebral edema or volume, such as osmotic diuretics.

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Correct Answer is A

Explanation

A. Excessive bleeding and hemorrhage: Disseminated intravascular coagulation (DIC) initially involves widespread activation of clotting, consuming platelets and coagulation factors. The resulting consumption coagulopathy leads to low platelet counts, prolonged PT and aPTT, and an increased risk of spontaneous bleeding and hemorrhage. These lab findings indicate the patient is in the consumptive, hypocoagulable phase of DIC.

B. Severe thrombocytosis and blood clots: Thrombocytosis refers to an elevated platelet count, which is not seen in this patient. In DIC, platelets are consumed, leading to thrombocytopenia rather than thrombocytosis, making clot formation due to excess platelets unlikely.

C. Acute renal failure due to hypercoagulation: While DIC can cause microvascular thrombosis affecting organs, the negative D-dimer and the current labs suggest the bleeding phase dominates rather than widespread thrombotic complications. Acute renal failure from hypercoagulation is less immediate than the risk of hemorrhage in this context.

D. Thrombosis leading to organ failure: Microthrombi can occur in DIC, but the patient’s lab profile, low platelets, prolonged PT and aPTT, and negative D-dimer, indicates a consumptive bleeding state. The immediate and highest-priority risk is excessive bleeding rather than thrombotic organ failure.

A. Coumadin B. Protamine sulfate C. Enoxaparin D. Vitamin K

Correct Answer is B

Explanation

A. Coumadin: Coumadin (warfarin) is an oral anticoagulant that inhibits vitamin K–dependent clotting factors. It is not effective in reversing the anticoagulant effects of heparin and would not be appropriate in the event of a heparin overdose.

B. Protamine sulfate: Protamine sulfate is a heparin antagonist that binds to heparin to form a stable complex, neutralizing its anticoagulant effect. It is administered intravenously and acts rapidly, making it the drug of choice for treating heparin overdose or excessive anticoagulation.

C. Enoxaparin: Enoxaparin is a low-molecular-weight heparin and functions similarly to unfractionated heparin by enhancing antithrombin III activity. It is not an antidote and would worsen anticoagulation if administered during a heparin overdose.

D. Vitamin K: Vitamin K is used to reverse the effects of vitamin K–dependent anticoagulants such as warfarin. It has no direct effect on heparin-induced anticoagulation and is not suitable for managing heparin overdose.

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A nurse is caring for a patient with increased intracranial pressure (ICP). The patient's most recent ICP reading is 22 mmHg. Which of the following actions should the nurse take immediately?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse knows that which drug should be readily available in case a patient experiences a heparin overdose?

Correct Answer is B

Explanation

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