When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply.
(Select All that Apply.)

Provide the patient a quiet and calm environment..

Minimize procedures that potentially produce agitation.

Facilitate an increased number of family visits to the patient.

Encourage the patient's family to increase patient interactions.

Observe the patient for signs of agitation or irritation and intervene.

Answer and Explanation

Correct Answer : A,B,E

A quiet and calm environment helps reduce stimuli that can increase ICP and cause discomfort.
B. Minimizing procedures that cause agitation prevents spikes in ICP and patient distress.
C. Too many or prolonged family visits can overstimulate the patient, increasing ICP and discomfort.
D. Excessive interaction may overstimulate the patient; interaction should be limited based on tolerance.
E. Early identification and intervention for agitation help maintain stable ICP and patient comfort.

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Correct Answer is B

Explanation

A. Headache is a common symptom but subjective and less reliable as an early sign of increased ICP.
B. Altered level of consciousness is the most sensitive and reliable early clinical indicator of increased ICP, reflecting impaired brain function.
C. Vital signs may remain stable initially; changes often occur later in the course of increased ICP.
D. Increased motor function is unlikely; motor deficits or decreased motor response are more common with increased ICP.

A. Log-rolls the client onto a slider board to transfer to the CT table B. Applies a hemostatic dressing over a bleeding facial laceration C. Inserts large-bore peripheral IVS for administration of IV contrast D. Administers PRN lorazepam for client reports of claustrophobia

Correct Answer is A

Explanation

A. Log-rolling maintains spinal alignment and prevents further injury when moving a client with a suspected cervical spine injury; this is the highest priority action.
B. Controlling bleeding is important but secondary to preventing spinal cord damage.
C. IV access is necessary for contrast administration but does not take priority over spinal precautions.
D. Managing anxiety is helpful but should not delay safe transfer and spinal precautions

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When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)?

Correct Answer is B

Explanation

A nurse is preparing a client with a possible cervical spine injury for a prescribed CT scan of the head and neck after the client sustained a fall down a stairwell. Which intervention by the nurse is the most important?

Correct Answer is A

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

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When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply.
(Select All that Apply.)