A wound care nurse is teaching a group of unit nurses about the vacuum-assisted closure system for healing of a pressure ulcer. Which of the following information should the nurse include in the teaching?

Rationale:

A. Elevate the head of the client's bed to 90°: A 90° elevation is excessive and can increase discomfort or lead to hypotension. A head-of-bed elevation of 30–45° is more appropriate to reduce intracranial pressure and support cerebral perfusion.

B. Keep the client's room dark and free from excess noise: Clients with encephalitis are highly sensitive to light and sound due to cerebral inflammation. Reducing sensory stimulation helps prevent agitation, seizures, and increased intracranial pressure.

C. Assist the client to turn, cough, and deep breathe every 4 hr: While preventing pulmonary complications is important, coughing can raise intracranial pressure. These activities should be done cautiously and only when clinically indicated in neurologically compromised clients.

D. Complete a neurological check on the client once every shift: Neurological assessments should be performed much more frequently often every 1 to 2 hours in clients with encephalitis to detect any early signs of deterioration or complications.

Rationale:

A. Bradycardia: While bradycardia can occur in late stages of shock or with certain medications, cardiogenic shock is more commonly associated with tachycardia as the body attempts to compensate for poor cardiac output by increasing heart rate.

B. Hypertension: In cardiogenic shock, blood pressure typically decreases due to the heart’s inability to effectively pump blood. Hypotension, not hypertension, is expected as perfusion to vital organs drops.

C. Increased urine output: A hallmark of cardiogenic shock is reduced perfusion to the kidneys, which results in decreased urine output. Oliguria or anuria may be an early sign of impaired organ perfusion in this condition.

D. Pulmonary congestion: Cardiogenic shock leads to impaired left ventricular function, causing blood to back up into the pulmonary circulation. This results in pulmonary congestion, a key finding that reflects worsening heart failure and reduced cardiac output.