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. Pain management is important, but it is not the highest priority compared to life-threatening complications like increased ICP.
B. Increased intracranial pressure is a critical and potentially life-threatening complication following a craniotomy. Monitoring for signs of increased ICP (e.g., altered level of consciousness, pupil changes, headache, vomiting) is a top priority to prevent brain herniation and other severe outcomes.
C. Infection is a concern, particularly at the surgical site, but it typically develops over time and is not as immediately life-threatening as increased ICP.
D. Hemorrhage is a serious complication, but signs of bleeding often contribute to increased ICP. Therefore, ICP monitoring encompasses broader neurological assessment and takes priority

A. Initiating an IV access peripherally B. Maintaining an open airway using the head tilt method C. Determining whether the patient is oriented to person, place, and time D. Applying a rigid cervical collar and using a backboard to transport the patient

Correct Answer is D

Explanation

A. IV access is important for fluid administration but does not prevent further spinal injury.
B. The head tilt method can worsen a cervical spine injury; instead, a jaw-thrust maneuver should be used to open the airway without neck movement.
C. Assessing orientation is part of the neurological exam but does not prevent further injury.
D. Applying a rigid cervical collar and using a backboard immobilizes the spine, preventing further spinal cord damage during transport.

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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.)

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Naxlex Comprehensive Predictor Exams

Which intervention would the nurse identify as a priority when monitoring a patient recovering from a craniotomy?

Correct Answer is B

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The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

Correct Answer is D

Explanation

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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.)