The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)
Encourage the patient to cough to expectorate secretions
Elevate the head of the bed to 30-45 degrees
Stimulate the patient with active range of motion exercises
Perform serial neurologic assessments while hospitalized
Contact the healthcare provider if the ICP is sustained between 30-40mmHg
Correct Answer : B,D,E
A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.
B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.
C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.
D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.
E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Neurogenic shock occurs in spinal cord injuries above T6 and is characterized by hypotension, bradycardia, and loss of sympathetic tone below the level of injury. This condition results from disruption of autonomic pathways.
B. Brain herniation typically involves increased intracranial pressure and different neurological symptoms.
C. Spinal shock involves temporary loss of reflexes and sensation but does not specifically cause bradycardia or hypotension.
D. Autonomic dysreflexia involves sudden high blood pressure and is usually triggered by noxious stimuli, occurring after the acute phase of SCI.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"D"},"C":{"answers":"B"},"D":{"answers":"C"}}
Explanation
Macular degeneration: This condition leads to the loss of central vision due to damage to the macula, which is responsible for sharp, straight-ahead vision.
Presbyopia: A common age-related condition resulting in a gradual loss of near visual acuity as the lens becomes less flexible, making it harder to focus on close objects.
Glaucoma: Typically causes loss of peripheral vision due to increased intraocular pressure damaging the optic nerve, eventually leading to tunnel vision if untreated.
Cataracts: Causes blurry vision as the lens becomes clouded, leading to general visual disturbance that progresses over time.
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