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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?

A.

Flex the client's hip.

B.

Hyperextend the client's neck.

C.

Provide warming measures for the client.

D.

Adjust the client's head of bed.

Answer and Explanation

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.
 


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

  • Administer furosemide: The patient has signs of pulmonary edema which needs to be managed.
  • Administer ordered Epinephrine drip: Epinephrine is crucial for managing hemodynamic instability.
  • Insert an indwelling urinary catheter: Monitoring urine output helps assess kidney function and fluid balance.
  • Administer ordered low dose dopamine: Useful for maintaining renal perfusion and blood pressure.
  • Administered 0.9% NS 500 mL bolus: Helps address hypotension and volume deficit.
  • Administer ordered nitroglycerin: Not needed in this acute post-arrest phase unless specifically indicated for managing ongoing angina or heart failure symptoms.

Correct Answer is []

Explanation

1. Condition: Acute Compartment Syndrome

Justification: The presence of severe pain, swelling, numbness, and a weak radial pulse along with delayed capillary refill are classic signs of acute compartment syndrome. Immediate surgical intervention (fasciotomy) is necessary to relieve the pressure within the muscle compartments.

2. Actions to Take

Prepare for Fasciotomy:

Justification: This surgical procedure will relieve the internal pressure causing the symptoms.

Request Prescription for Pain Medication:

Justification: Adequate pain management is important for client comfort and can also indicate response to treatment.

3. Parameters to Monitor

Neurovascular Status:

Justification: Monitoring for further deterioration of symptoms such as worsening numbness or weak pulses is essential.

WBC Count:

Justification: Helps in the broader assessment of possible infection, though not directly related to acute compartment syndrome

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