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 []
Explanation
Condition:
A. Transfusion-associated circulatory overload (TACO)
Rationale: The client’s symptoms—dyspnea, restlessness, crackles in the lungs, jugular vein distension, and elevated blood pressure—are consistent with TACO, a condition resulting from excessive fluid volume during a blood transfusion.
Actions to Take:
C. Administer furosemide
Rationale: Furosemide is a diuretic that helps reduce fluid overload, which is a key issue in TACO.
B. Administer diphenhydramine
Rationale: Although not the primary treatment for TACO, diphenhydramine can help manage symptoms if there is a mild allergic reaction contributing to the situation.
Parameters to Monitor:
A. Intake and output
Rationale: Monitoring intake and output helps assess fluid balance and effectiveness of treatment for TACO.
D. Weight
Rationale: Weight monitoring helps assess fluid overload and effectiveness of diuretic therapy
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A,B"}}
Explanation
1. Provider Consult
Angina: Not typically associated with immediate provider consultation.
MI: Requires immediate consultation for treatment decisions, such as medication or interventions.
2. Client's Initial Report of Manifestations
Angina: Can present with discomfort or pressure that is transient and relieved by rest or nitroglycerin.
MI: Can present similarly but is often more severe and sustained; discomfort may be a precursor to a myocardial infarction.
3. Treadmill Stress Test
Angina: Often used to provoke symptoms under controlled conditions for diagnosis.
MI: Not used during an acute phase; rather, diagnostics are performed through EKG and cardiac enzyme tests.
4. Result of Nitroglycerin Therapy
Angina: Relief from nitroglycerin indicates angina.
MI: Nitroglycerin might not provide relief; other treatments and diagnostics are needed.
5. 12 Lead EKG Report
Angina: ST depression and T-wave inversion can occur with angina.
MI: These EKG changes can indicate ischemia, which could be part of an acute MI if accompanied by other severe symptoms or in the presence of persistent symptoms.
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