A nurse is preparing to suction a 5-year-old child with a severe traumatic brain injury who is intubated.
Which of the following actions is most appropriate to prevent a rise in intracranial pressure (ICP)?
Administer sedation prior to suctioning.
Lower the head of the bed to increase venous return.
Perform suctioning as quickly as possible.
Delay suctioning until ICP rises.
The Correct Answer is A
Choice A rationale
Administering sedation (e.g., narcotics or benzodiazepines) prior to invasive procedures like suctioning is crucial to blunt the reflex sympathetic response. Suctioning can induce coughing, gagging, and pain, which dramatically increase systemic blood pressure and, consequently, cerebral blood volume and intracranial pressure (ICP), leading to secondary brain injury. Sedation provides analgesia and anxiolysis, minimizing these adverse physiological reactions.
Choice B rationale
Lowering the head of the bed (HOB) can increase cerebral blood flow and impede venous drainage from the head and neck vessels, thereby increasing cerebral blood volume and consequently intracranial pressure (ICP). For a child with severe traumatic brain injury, the HOB should typically be elevated to 30 degrees to promote optimal venous outflow and pressure regulation.
Choice C rationale
While performing suctioning quickly minimizes the duration of the noxious stimulus, it does not address the initial reflexive physiological response to the stimulus itself, which triggers the rise in ICP. The most effective preventative measure is to pre-oxygenate and administer sedation to mitigate the body's adverse reaction before and during the necessary procedure.
Choice D rationale
Delaying suctioning until ICP has already risen is a reactive measure, not a preventative one, and risks secondary brain injury from sustained or high-peak ICP. Suctioning must be performed when secretions compromise airway patency, but the goal is to mitigate the expected ICP rise through proactive interventions like pre-sedation and hyperoxygenation before the procedure is initiated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Periorbital edema (swelling around the eyes) is a common sign of nephrotic syndrome or other systemic fluid overload states, such as congestive heart failure. While heart failure can be a complication of severe infective endocarditis (IE), periorbital edema is a non-specific finding and not a primary, classic physical finding of the infection itself.
Choice B rationale
Bounding pulses in the lower extremities are most characteristic of a condition causing a wide pulse pressure, such as a large patent ductus arteriosus (PDA) or aortic regurgitation. While aortic valve damage can occur in IE, the bounding pulse is not a hallmark finding directly resulting from the infectious process.
Choice C rationale
A high-pitched cry is a non-specific sign of neurological distress or pain in an infant. While systemic infection and potential septic emboli from infective endocarditis could affect the central nervous system, this symptom is not a primary or expected clinical manifestation of the localized heart valve infection.
Choice D rationale
Splinter hemorrhages are small, linear, dark-red streaks that appear under the nails. They are a classic peripheral sign of infective endocarditis caused by microemboli (tiny fragments of the infected vegetation) lodging in the distal capillaries of the nail bed, making this a highly indicative finding.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Frontal bossing (prominent forehead) is a sign of long-standing, chronic increased intracranial pressure (ICP), as the cranial sutures separate to accommodate the increased volume. In infants, the cranium can enlarge, but frontal bossing is generally a later sign, not an early indicator of acutely rising ICP.
Choice B rationale
A bulging fontanel is an early and crucial sign reflecting an acute rise in intracranial pressure (ICP) due to excess cerebrospinal fluid accumulation within the ventricles. The fontanel's tenseness indicates pressure transmission, as the open sutures allow expansion, which is a key compensatory mechanism in the infant skull.
Choice C rationale
Poor feeding is a non-specific but common early sign of increased intracranial pressure (ICP), which affects the brainstem centers controlling appetite and satiety. The pressure can also induce nausea and vomiting due to direct stimulation of the emetic center, contributing to decreased oral intake.
Choice D rationale
Dilated scalp veins are an early compensatory response to increased intracranial pressure (ICP). The rising pressure impedes venous return from the brain through the dural sinuses, causing a backup that manifests as visibly engorged and dilated veins on the scalp.
Choice E rationale
Bradycardia is a component of the Cushing's triad (along with widening pulse pressure and irregular respirations), signifying a critical, though sometimes early, response to severe elevation of intracranial pressure (ICP), primarily through stimulation of the vagus nerve.
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