A nurse is planning care for a child who is unresponsive and has increased intracranial pressure. Which of the following actions should the nurse take?

Schedule routine oral suctioning

Pad the side rails of the bed.

Obtain isolation supplies

Place the child in Trendelenburg position

Answer and Explanation

The Correct Answer is B

A. Schedule routine oral suctioning: Suctioning can increase intracranial pressure and should be performed only when necessary, using short, gentle passes. Routine suctioning is not recommended for a child with increased ICP, as it can exacerbate neurological injury.

B. Pad the side rails of the bed: An unresponsive child is at high risk for injury from involuntary movements or seizures. Padding the side rails helps prevent trauma and is a key safety intervention in children with increased intracranial pressure, making it the priority action in this scenario.

C. Obtain isolation supplies: Isolation precautions are only needed if the child has a contagious condition. Increased intracranial pressure does not automatically indicate a risk of infection transmission, so isolation supplies are not immediately necessary.

D. Place the child in Trendelenburg position: Trendelenburg positioning (head-down) can further increase intracranial pressure and is contraindicated. Children with elevated ICP should be positioned with the head of the bed elevated to promote venous drainage and reduce pressure.

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Correct Answer is D

Explanation

A. Compensation: Compensation involves emphasizing a strength to make up for a perceived weakness or deficiency. Preparing a deceased partner’s favorite meals does not serve to offset a personal deficiency, so this is not the correct defense mechanism.

B. Dissociation: Dissociation is the temporary detachment from reality or identity to cope with stress or trauma. Cooking familiar meals does not indicate a detachment from reality; the client is fully aware of their actions and circumstances.

C. Rationalization: Rationalization involves creating logical explanations to justify unacceptable behaviors or feelings. Cooking meals for a deceased partner is not an attempt to justify behavior but a coping mechanism, so rationalization does not apply.

D. Denial: Denial is a defense mechanism in which a person refuses to accept reality or facts to avoid emotional pain. Continuing to cook meals for a deceased partner reflects the client’s difficulty accepting the loss, making denial the most appropriate identification of their behavior.

A. Cleansing the insertion site daily B. Covering the insertion site with a transparent dressing C. Administering supplemental opioids as needed D. Replacing the infusion tubing every 72 hr

Correct Answer is B

Explanation

A. Cleansing the insertion site daily: Frequent cleansing of an epidural insertion site is not recommended because excessive manipulation increases the risk of infection. Standard practice is to keep the site clean and dry, assessing it regularly without daily cleaning unless contamination occurs.

B. Covering the insertion site with a transparent dressing: Using a sterile, transparent dressing allows continuous visualization of the insertion site for early signs of infection, leakage, or inflammation. It protects the site while permitting ongoing assessment, which is essential for clients receiving epidural analgesia.

C. Administering supplemental opioids as needed: Supplemental opioids should be used cautiously in clients with epidural analgesia because they can increase the risk of respiratory depression and sedation. Pain management should primarily rely on the epidural infusion and follow prescribed protocols rather than routine PRN systemic opioids.

D. Replacing the infusion tubing every 72 hr: Epidural infusion tubing typically should be replaced according to institutional protocol, often every 24 hours, not 72 hours, to reduce the risk of infection. Extending tubing changes beyond recommended intervals increases the likelihood of contamination and catheter-related complications.

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A nurse is planning care for a child who is unresponsive and has increased intracranial pressure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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