A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?
Flex the client's hip.
Hyperextend the client's neck.
Provide warming measures for the client.
Adjust the client's head of bed.
The Correct Answer is D
A. Flex the client’s hip is incorrect. Flexing the hip can increase intra-abdominal pressure and potentially increase intracranial pressure.
B. Hyperextend the client’s neck is incorrect. Hyperextension of the neck can interfere with venous return from the brain and increase ICP.
C. Provide warming measures for the client is incorrect. Warming measures are not indicated for a low CPP; maintaining normothermia is important, but warming is not the priority action.
D. Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wide grip utensils may help with grasp but do not address visual field deficits.
B. Homonymous hemianopsia involves loss of vision in one half of the visual field; reminding the client to look to the left side of the tray helps them find food in their impaired visual field.
C. Using the right hand is not specifically beneficial for visual field deficits and may not address the issue of homonymous hemianopsia.
D. A nonskid mat helps prevent plate movement but does not address the visual field deficit caused by homonymous hemianopsia.
Correct Answer is ["250"]
Explanation
- Total volume of IV fluid: 2000 mL
- Total time for infusion: 8 hours
Infusion rate: 2000/8 = 250ml/hr
=250
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