Which Nursing Intervention for the Patient with Increased Intracranial Pressure would be first priority?
Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway
Maintain a calm, quiet atmosphere and protect patient from stress
Use strict aseptic technique for management of ICP monitoring system
Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage
The Correct Answer is A
Choice A: Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway is the first priority, as it can prevent hypoxia, hypercapnia, and increased ICP that can lead to brain herniation and death.
Choice B: Maintain a calm, quiet atmosphere and protect patient from stress is not the first priority, but rather a supportive measure to reduce stimuli and agitation that can increase ICP.
Choice C: Use strict aseptic technique for management of ICP monitoring system is not the first priority, but rather a preventive measure to avoid infection and meningitis that can worsen ICP.
Choice D: Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage is not the first priority, but rather a therapeutic measure to facilitate blood flow and reduce ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Headache is not a late sign of intracranial pressure, but rather an early sign of increased pressure or irritation of the meninges.
Choice B: Confusion is not a late sign of intracranial pressure, but rather an early sign of impaired cognition or orientation.
Choice C: Stupor to coma is a late sign of intracranial pressure, as it indicates a severe deterioration of consciousness or brain function.
Choice D: Weakness is not a late sign of intracranial pressure, but rather a sign of focal neurological deficit or hemiparesis.
Correct Answer is D
Explanation
Choice A: Ethnicity is not a modifiable risk factor of strokes, as it is determined by genetic and cultural factors that cannot be changed.
Choice B: Gender is not a modifiable risk factor of strokes, as it is determined by biological and hormonal factors that cannot be changed.
Choice C: Age is not a modifiable risk factor of strokes, as it is determined by chronological factors that cannot be changed.
Choice D: Obesity is a modifiable risk factor of strokes, as it can be reduced by lifestyle changes such as diet and exercise. Obesity can increase the risk of strokes by causing high blood pressure, diabetes, and heart disease.
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