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

Answer and Explanation

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

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Correct Answer is A

Explanation

A. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.

B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.

C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.

D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.

A. Ability to process multiple pieces of information at the same time B. Playing chess with fellow patients within one week of admission C. Difficulty planning and organizing thoughts and behaviors D. Being increasingly non-compliant with therapeutic care plans

Correct Answer is C

Explanation

A. Chronic head injury patients often struggle with processing multiple pieces of information simultaneously due to cognitive limitations.

B. Activities requiring complex strategy, like chess, are typically challenging shortly after admission and not a realistic expectation.

C. Difficulty with planning and organizing thoughts and behaviors is a common cognitive deficit in patients with chronic head injury due to impaired executive function, often resulting from damage to the frontal lobe.

D. While non-compliance can occur, it is less predictable and may not be directly linked to chronic head injury itself.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

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)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for several patients in the Intensive Care Unit. Which of the following patients is at greatest risk of anoxic brain injury? A patient who:

Correct Answer is A

Explanation

Which behavior(s) by the patient diagnosed with a chronic head injury would the nurse expect to find?

Correct Answer is C

Explanation

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