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 B

Explanation

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

A. "Using three drugs at the same time enhances suppression of viral replication." B. "If the virus becomes resistant to this combination, I will be switched to another combination of medications." C. "Because the combination of medications kills the virus, I can stop taking the medications." D. "My CD4 count should increase with this medication regimen."

Correct Answer is C

Explanation

A. This is a correct statement, as using multiple drugs helps to reduce the likelihood of resistance and enhances viral suppression.

B. This is accurate; if resistance develops, alternative medications or combinations can be considered.

C. This statement indicates a misunderstanding. Antiretroviral medications do not kill the virus; they suppress its replication. Lifelong adherence to antiretroviral therapy is necessary to manage HIV and prevent viral rebound.

D. Correct, as an effective regimen should lead to an increase in CD4 count and improved immune function.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Correct Answer is B

Explanation

Which statement made by a patient who is diagnosed with human immunodeficiency virus (HIV) and is prescribed three antiretroviral medications, indicates the need for further teaching about the medication combination?

Correct Answer is C

Explanation

A nurse is preparing to administer clonidine 0.3 mg at bedtime to a patient. The amount available is clonidine 0.1 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

The nurse is caring for a patient with mitral valve disease. At which anatomic landmark will the nurse hear a heart murmur the loudest?

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate a prescription for which of the following medications to manage increases in intracranial pressure (ICP)?

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