A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?
Perform active range-of-motion exercises.
Maintain the head at a midline position.
Suction the airway frequently.
Perform neurological checks every 4 hours.
The Correct Answer is B
A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.
B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.
C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.
D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A.
A. Early decelerations are typically benign and occur in response to head compression during contractions. They mirror the uterine contractions and are not associated with fetal distress.
B. Fetal hypoxia is associated with variable or late decelerations, not early decelerations.
C. Abruptio placentae is a medical emergency characterized by premature separation of the placenta from the uterine wall, which can lead to late decelerations due to fetal hypoxia.
D. Postmaturity is a term used to describe a pregnancy that extends beyond 42 weeks gestation and is not directly related to fetal heart rate patterns during labor.
Correct Answer is D
Explanation
A. Taking pancrelipase on an empty stomach may not provide optimal effectiveness as there would be no food in the stomach to mix with the enzymes for proper digestion.
B. Taking pancrelipase 1 hour before meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.
C. Taking pancrelipase 1 hour after meals may not be as effective as taking it with meals because the enzymes need to be present when food enters the stomach for digestion.
D. Taking pancrelipase with meals is the correct instruction. Pancrelipase supplements the digestive enzymes that are deficient in individuals with cystic fibrosis, helping them digest food properly. Taking it with meals ensures that the enzymes are present when food enters the stomach, optimizing digestion and nutrient absorption.
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