A nurse is preparing to administer medications to a client. Which action best aligns with the National Patient Safety Goals?

Asking another nurse to confirm the client's identity

Using the client's name and date of birth to verify identity

Comparing the client's wristband to the room assignment sheet

Asking the client to confirm their room number

Answer and Explanation

The Correct Answer is B

Patient identification safety protocols are critical components of medication administration to prevent adverse drug events. The National Patient Safety Goals emphasize the use of at least two independent identifiers to accurately verify patient identity prior to delivering medications, procedures, or treatments in all healthcare settings.

Rationale:

A. Asking another nurse to confirm identity introduces potential confirmation bias and does not independently verify the patient using standardized identifiers. The National Patient Safety Goals require direct verification using two approved identifiers rather than indirect staff-based confirmation.

B. Using the client’s name and date of birth represents two approved patient identifiers as required by safety standards. This method reduces medication errors by ensuring accurate linkage between the medication order and the correct individual before administration.

C. Comparing wristband to room assignment is unreliable because room numbers can change due to transfers or shared rooms. The National Patient Safety Goals specifically discourage use of location-based identifiers due to high risk of misidentification and patient safety errors.

D. Asking for room number is not a valid identifier because patients may be disoriented, transferred, or unaware of their assigned location. Room numbers are excluded from acceptable identifiers under patient safety protocols due to lack of reliability in clinical environments.

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Correct Answer is B

Explanation

Increased intracranial pressure involves elevated cerebral fluid volume, impaired venous outflow, reduced cerebral perfusion pressure, and risk of brain tissue herniation. Positioning plays a critical role in optimizing venous drainage, reducing intracranial pressure, and maintaining adequate oxygen delivery to brain tissues.

Rationale:

A. Prone positioning increases intrathoracic pressure and can obstruct venous return from the brain, worsening intracranial pressure. It also compromises airway access and oxygenation in neurologically unstable clients. Increased venous congestion and impaired cerebral drainage can further elevate intracranial pressure.

B. Elevating the head of the bed to approximately 30 degrees promotes optimal cerebral venous drainage and reduces intracranial pressure. This position enhances jugular venous outflow while maintaining adequate cerebral perfusion. Improved venous return and reduced intracranial volume pressure help prevent secondary brain injury.

C. Flat positioning decreases venous drainage from the brain and increases intracranial blood volume, worsening intracranial pressure. It promotes cerebral congestion and reduces the effectiveness of gravity-assisted venous return. This leads to increased intracranial blood volume and impaired cerebral perfusion dynamics.

D. Trendelenburg position significantly increases intracranial pressure by promoting head-directed blood flow and impairing venous drainage. This position is contraindicated in clients with elevated intracranial pressure. It exacerbates cerebral congestion and reduces effective intracranial pressure control mechanisms.

A. Coma B. Headache C. Fixed pupils D. Posturing

Correct Answer is B

Explanation

Increased intracranial pressure involves rising intra-cranial volume, reduced cerebral perfusion pressure, impaired neuronal oxygenation, and progressive brain tissue compression. Early recognition is essential to prevent secondary brain injury, herniation syndromes, and irreversible neurologic deterioration in clients with head trauma.

Rationale:

A. Coma is a late and severe manifestation of increased intracranial pressure indicating significant cerebral dysfunction and brainstem involvement. It reflects advanced neurologic deterioration rather than an early warning sign. Loss of consciousness and profound cerebral depression occur in later stages of intracranial hypertension.

B. Headache is an early and common sign of increased intracranial pressure due to stretching of pain-sensitive intracranial structures such as dura mater and blood vessels. It often precedes more severe neurologic changes. Increased intracranial tension and reduced cerebral compliance contribute to persistent headache symptoms.

C. Fixed pupils indicate severe brainstem compression and are a late and life-threatening sign of increased intracranial pressure. This finding suggests impending herniation and requires emergency intervention. It reflects loss of cranial nerve function and advanced brainstem compromise.

D. Posturing (decorticate or decerebrate) is a late neurologic sign indicating severe brain injury and brainstem involvement. It represents significant disruption of motor pathways and increased intracranial pressure progression. Abnormal motor response patterns and severe neurologic impairment occur at advanced stages of intracranial hypertension.

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A nurse is preparing to administer medications to a client. Which action best aligns with the National Patient Safety Goals?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with increased intracranial pressure is being repositioned. Which position should the nurse implement to promote optimal cerebral venous drainage?

Correct Answer is B

Explanation

A client with a head injury begins to report worsening symptoms. Which finding should the nurse recognize as an early sign of increased intracranial pressure (ICP)?

Correct Answer is B

Explanation

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