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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. A ketogenic diet does not focus on high sodium or high sugar, as high sugar intake would increase carbohydrate levels.

B. A ketogenic diet is high in fat rather than low in fat.

C. High carbohydrates are avoided in a ketogenic diet, as the goal is to limit carbohydrates to promote ketone production.

D. The ketogenic diet consists of high fat and low carbohydrates, which helps to manage seizure activity by altering the brain's energy source to ketones rather than glucose.

A. Take this medication with food or milk B. Get potassium levels drawn periodically C. Increase intake of green vegetables D. Use salt substitute for cooking

Correct Answer is B

Explanation

A. While taking some medications with food or milk can help with absorption, this is not a specific requirement for lisinopril.

B. Lisinopril, an ACE inhibitor, can lead to elevated potassium levels. Periodic monitoring of potassium levels is essential to prevent hyperkalemia, a potentially dangerous side effect.

C. Increasing intake of green vegetables is generally healthy but does not directly impact lisinopril's effects.

D. Many salt substitutes contain potassium, which could elevate potassium levels further when taken with ACE inhibitors like lisinopril, posing a risk for hyperkalemia.

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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?

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Naxlex Comprehensive Predictor Exams

The patient who is diagnosed with a seizure disorder is prescribed a ketogenic diet. The nurse knows that the patient understands the teaching when they state, "My diet will include:

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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