Which nursing intervention is contraindicated in a patient with increased intracranial pressure (ICP)?
Applying a tight cervical collar
Monitoring ABGS
Administering antipyretics for fever
Elevating the head of bed to 30 degrees
The Correct Answer is A
A. Applying a tight cervical collar is correct as contraindicated because a tight or improperly fitted collar can increase ICP by restricting venous drainage from the brain. Proper spinal immobilization is important in trauma patients, but collars should be appropriately sized and not overly tight, and adjustments should be made to avoid raising ICP.
B. Monitoring ABGs is incorrect because assessing arterial blood gases is essential in patients with increased ICP. ABGs help evaluate oxygenation and carbon dioxide levels, which directly affect cerebral blood flow and ICP.
C. Administering antipyretics for fever is incorrect because controlling fever is important; hyperthermia increases cerebral metabolism and can worsen ICP. Antipyretics help reduce metabolic demand and prevent ICP spikes.
D. Elevating the head of bed to 30 degrees is incorrect because head-of-bed elevation promotes venous drainage from the brain, which helps reduce ICP. This is a standard nursing intervention in patients with increased ICP.
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Related Questions
Correct Answer is C
Explanation
A. Normal ICP is incorrect because normal intracranial pressure ranges from 5 to 15 mmHgin adults. Values above 20 mmHg are considered elevated, and sustained ICP above 20–25 mmHg is critically highand requires urgent intervention.
B. Mildly elevated ICP is incorrect because ICP of 28 mmHg exceeds mild elevation, which is generally considered 20–25 mmHg. This patient’s ICP is above that range and represents a dangerous level.
C. Critically elevated ICP is correct. An ICP of 28 mmHg indicates critically elevated intracranial pressure, especially when accompanied by low CPP (normal 60–70 mmHg)and hypercapnia (PaCO2 60 mmHg). Hypercapnia causes cerebral vasodilation, further increasing ICP and worsening cerebral perfusion. Immediate interventions are required to reduce ICP, optimize CPP, and prevent secondary brain injury.
Correct Answer is B
Explanation
A. The patient has a cough for the last 5 days is incorrect because while a prolonged cough may require assessment and management, it is not immediately life-threatening in the context of ICP monitoring. It is a secondary concern compared to potential complications of the monitoring system itself.
B. Cloudy cerebrospinal fluid drainage is correct because cloudy CSF is a sign of possible infection, such as ventriculitis or meningitis. Patients with ventriculostomy drains or ICP monitors are at high risk for infections due to the direct access of the central nervous system. Infection in this context is a serious and urgent concern that can increase ICP, worsen neurological status, and rapidly become life-threatening. Immediate notification of the healthcare provider and implementation of infection-control measures are required.
C. You notice a rash developing on his coccyx is incorrect because while a pressure injury is concerning and requires intervention, it is not as immediately critical as signs of CNS infection in a patient with ICP monitoring.
D. Cerebrospinal fluid production at 20 mL/hr is incorrect because normal CSF production ranges from approximately 20–30 mL/hr (about 500 mL/day). This rate is within expected limits and not concerning in itself.
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