A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

Maintain hyperventilation to a PaCO2 of 15 to 20mm Hg.

Routinely suction to prevent accumulation of respiratory secretions

Encourage visitation to prevent feelings of isolation.

Avoid positioning the client with neck and hip flexion.

Answer and Explanation

The Correct Answer is D

A. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. Hyperventilation can reduce ICP by causing vasoconstriction of cerebral blood vessels; however, a PaCO2 as low as 15–20 mmHg may lead to excessive vasoconstriction, reducing cerebral blood flow and causing cerebral ischemia. A PaCO2 target closer to 30–35 mmHg is typically recommended, and even this is used cautiously.

B. Routinely suction to prevent accumulation of respiratory secretions. Suctioning can increase ICP due to stimulation of the cough reflex. It should be performed only as needed and in a way that minimizes stimulation, such as preoxygenation and limiting suction duration.

C. Encourage visitation to prevent feelings of isolation. While social support is important, minimizing environmental stimuli (including limiting visitation) is crucial for clients with increased ICP to prevent overstimulation and further increases in ICP.

D. Avoid positioning the client with neck and hip flexion. Maintaining proper alignment of the head and neck is essential to promote venous drainage and reduce intracranial pressure (ICP). Flexion of the neck or hips can impede venous outflow, exacerbate ICP, and compromise cerebral perfusion.

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Correct Answer is A

Explanation

A. 3% hypertonic saline: In SIADH, the body holds onto too much water, leading to dilutional hyponatremia. Hypertonic saline helps to slowly raise the sodium level and correct the dilution.

B. Normal saline solution: Normal saline (0.9%) would not be effective for SIADH as it is isotonic and would not correct the sodium imbalance.

C. Dextrose 5% in water: This would not be appropriate, as it contains free water and could exacerbate hyponatremia in a client with SIADH.

D. Lactated Ringers: This is an isotonic solution and would not effectively address the dilutional hyponatremia caused by SIADH.

A. Thrombotic stroke B. Embolic stroke C. Hemorrhagic stroke D. Transient ischemic attack (TIA)

Correct Answer is C

Explanation

A. Thrombotic stroke. A thrombotic stroke develops more gradually and is not typically associated with such sudden and severe symptoms.

B. Embolic stroke. An embolic stroke is often associated with a known embolic source, such as a clot from the heart, and can present more suddenly, but without all the symptoms seen here.

C. Hemorrhagic stroke: Hemorrhagic strokes often present with a sudden, severe headache, vomiting, seizure activity, and high blood pressure. A fever may also develop due to increased intracranial pressure.

D. Transient ischemic attack (TIA). TIAs are brief and resolve within minutes to hours and do not typically cause seizures.

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A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

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