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 D

Explanation

A. Administration of prescribed Atropine. Atropine is typically used for bradycardia related to second-degree heart block Mobitz 2 or complete block, but Mobitz 1 usually resolves on its own and does not require atropine unless symptoms develop.

B. A prescription for transcutaneous pacing. Transcutaneous pacing is typically used for more severe types of heart block, such as Mobitz 2 or third-degree block, not Mobitz 1.

C. An extra dose of digoxin will be prescribed. Giving additional digoxin would be contraindicated due to its effects on AV conduction.

D. The next dose of digoxin will be held: Second-degree heart block Mobitz 1 (also known as Wenckebach) can be worsened by digoxin, which has a vagomimetic effect that can slow conduction through the AV node. Therefore, the next dose of digoxin should be held to avoid further exacerbating the block.

A. Congenital valve abnormalities B. Rheumatic fever C. Autoimmune deficiency syndrome D. Degenerative calcification of valve

Correct Answer is B

Explanation

A. Congenital valve abnormalities: Although congenital heart defects can cause aortic stenosis, rheumatic fever is a more common cause in adults.

B. Rheumatic fever: Rheumatic fever is the most common cause of aortic stenosis in adults, as it can lead to scarring and narrowing of the aortic valve.

C. Autoimmune deficiency syndrome: This is not associated with aortic stenosis.

D. Degenerative calcification of valve: This is a common cause of aortic stenosis in older adults, but it is generally less common than rheumatic fever as the primary cause in a younger or middle-aged population.

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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

The patient is asymptomatic but is diagnosed with second-degree heart block Mobitz 1. The patient is on digoxin at home. Which of the following interventions will the nurse anticipate?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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