The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?
Suction the patient to minimize secretions
Continue with the assessment and document the finding
Notify the physician and raise HOB to 35-45 degrees
Lower the head of the bed and pad the side rails
The Correct Answer is C
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.
B. Documenting without intervention could lead to worsening of the patient's condition.
C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.
D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.
Correct Answer is D
Explanation
A. Touching a patient’s shoulder does not pose a risk of HIV transmission, as it is not spread through casual skin contact.
B. While recapping needles is discouraged due to the risk of needlestick injury, it is not an exposure unless an actual needlestick occurs.
C. Not wearing a mask is typically not necessary in all interactions with HIV/AIDS patients unless there is an active infection requiring airborne precautions.
D. Exposure of bodily fluids to mucous membranes (such as the eyes) is a significant occupational exposure risk and should be reported. This requires immediate response and evaluation for potential infection.
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