The nurse is caring for a client in the ICU who is experiencing brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure is 70 mmHg with an intracranial pressure reading of 15 mmHg. What is the nurse's most appropriate action?
Administer osmotic diuretics as prescribed and open drain to remove cerebrospinal fluid
Participate in interventions to increase cerebral perfusion pressure
Prepare the client for having burr holes drilled into the skull
Position the client in the high Fowler position as tolerated
The Correct Answer is B
A. Administer osmotic diuretics as prescribed and open drain to remove cerebrospinal fluid: Osmotic diuretics and CSF drainage are used to lower elevated intracranial pressure. In this scenario, the ICP is 15 mmHg, which is within normal limits, so lowering ICP is not the immediate priority.
B. Participate in interventions to increase cerebral perfusion pressure: Cerebral perfusion pressure (CPP) is calculated as MAP minus ICP. With a MAP of 70 mmHg and ICP of 15 mmHg, CPP is 55 mmHg, which is at the lower threshold of adequate cerebral perfusion. Supporting CPP through interventions is critical to maintain brain oxygenation and prevent further injury.
C. Prepare the client for having burr holes drilled into the skull: Surgical intervention is reserved for cases of refractory intracranial hypertension or localized mass effect. This is not immediately indicated given the current ICP and MAP values.
D. Position the client in the high Fowler position as tolerated: While positioning can influence ICP, high Fowler may actually reduce cerebral perfusion by lowering MAP relative to ICP. Maintaining neutral alignment and interventions to optimize CPP are higher priorities in brain stem herniation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Mitral valve stenosis: Narrowing of the mitral valve impedes blood flow from the left atrium to the left ventricle, causing increased left atrial pressure and pulmonary congestion. Chronic pulmonary hypertension can develop, leading to right ventricular hypertrophy and eventual right-sided heart failure.
B. Aortic valve regurgitation: This primarily affects the left ventricle, causing volume overload and left ventricular dilation, rather than directly impacting right ventricular function.
C. Aortic valve stenosis: Aortic stenosis leads to left ventricular hypertrophy due to increased afterload, and right ventricular involvement occurs only secondarily if pulmonary hypertension develops, making it a less direct contributor.
D. Mitral valve regurgitation: While mitral regurgitation increases left atrial pressure and can cause pulmonary hypertension over time, it is less commonly associated with isolated right ventricular hypertrophy compared with mitral stenosis.
Correct Answer is D
Explanation
A. 56-year-old who is recovering from a laparoscopic cholecystectomy and has severe shoulder pain: Shoulder pain is common after laparoscopic surgery due to diaphragmatic irritation from residual CO₂. While uncomfortable, it is not immediately life-threatening and does not require rapid assessment.
B. 50-year-old with chronic pancreatitis who has gnawing abdominal pain: Chronic pancreatitis causes recurrent abdominal pain, which is usually managed with analgesics and monitoring. This is concerning for comfort and chronic disease management but does not indicate an acute emergency.
C. 48-year-old who has compensated cirrhosis and is complaining of anorexia: Anorexia is a common symptom in cirrhosis but is not acutely life-threatening. Assessment is important but not urgent compared to potential infection or decompensation.
D. 45-year-old with cirrhosis and severe ascites who has an oral temperature of 102° F (38.8° C): Fever in a client with cirrhosis and ascites raises concern for spontaneous bacterial peritonitis, a life-threatening infection. Rapid assessment and intervention are critical to prevent sepsis and hemodynamic instability, making this the highest priority.
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