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. Remind the client to look for food on the left side of the tray: Homonymous hemianopsia is a condition in which a person loses vision in the same half of the visual field of each eye (in this case, the left visual field due to right-sided brain damage). The nurse should remind the client to look for food on the left side of the tray to help compensate for the visual deficit.

B. Provide a non-skid mat to alleviate plate movement. While a non-skid mat can help with plate stability, it does not address the visual field loss caused by homonymous hemianopsia.

C. Encourage the client to use his right hand when feeding himself. There is no specific benefit to using the right hand when a client is experiencing a visual deficit in the left visual field. Instead, compensating for the visual field loss is the priority.

D. Encourage the use of the wide grip utensils. Wide grip utensils are helpful for clients with limited hand mobility but will not address the specific visual impairment caused by homonymous hemianopsia.

A. Document the finding and continue to monitor the client. B. Prepare the client for temporary pacemaker insertion. C. Notify the client's health care provider immediately and then administer epinephrine IV. D. Administer atropine per agency bradycardia protocol and then notify the health care provider

Correct Answer is A

Explanation

A. Document the finding and continue to monitor the client: A PR interval of 0.24 seconds indicates first-degree AV block, which is often asymptomatic and benign if vital signs are stable. No immediate intervention is required other than continued monitoring.

B. Prepare the client for temporary pacemaker insertion: Pacemakers are not indicated for asymptomatic first-degree AV block.

C. Notify the health care provider immediately and then administer epinephrine IV: This is unnecessary as the client is stable and shows no signs of hemodynamic compromise.

D. Administer atropine per agency bradycardia protocol and then notify the health care provider: Atropine is not required for a stable heart rate of 72 bpm.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hernianopsia when eating. Which action should the nurse take?

Correct Answer is A

Explanation

The nurse is evaluating a cardiac monitor strip for their client that displays a sinus rhythm with a heart rate of 72 bpm. The PR interval is 0.24 seconds. The vital signs are stable and the client reports no symptoms. What is the most appropriate nursing intervention?

Correct Answer is A

Explanation

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