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
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
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
Correct Answer is C
Explanation
A. Nitroprusside is a vasodilator and is not used for managing ICP; it can increase intracranial pressure if not carefully monitored.
B. Furosemide is a diuretic but is less effective for ICP reduction compared to hypertonic saline or mannitol.
C. Hypertonic saline (3% Normal Saline) is used to reduce intracranial pressure by drawing fluid out of the brain tissue and into the bloodstream, which can help prevent cerebral edema.
D. Norepinephrine is a vasopressor and is not used specifically to manage intracranial pressure.
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