Which of the following are nursing interventions related to body positioning when caring for a patient with increased ICP?

Elevate HOB to 30 degrees

Make sure patient has a bowel movement everyday

Turn patient with slow, gentle movements to prevent increase in ICP

Place patient in prone position every 2 hours

Answer and Explanation

Correct Answer : A,C

A. Elevate HOB to 30 degrees is correct because head-of-bed elevation promotes venous drainage from the brain, which can help reduce intracranial pressure. This position also supports adequate cerebral perfusion while avoiding neck flexion or extreme hip flexion, which can impair venous outflow and worsen ICP.

B. Make sure patient has a bowel movement every day is incorrect in the context of body positioning. While preventing constipation is important in patients with increased ICP to avoid straining (Valsalva maneuver), it is not a direct positioning intervention.

C. Turn patient with slow, gentle movements to prevent increase in ICP is correct because sudden or vigorous movements can transiently increase ICP. Gentle, coordinated turning and repositioning help minimize fluctuations in intracranial pressure and reduce the risk of neurological deterioration.

D. Place patient in prone position every 2 hours is incorrect because prone positioning is generally avoided in patients with increased ICP. Prone positioning can impair venous return from the brain, increase ICP, and compromise airway management. Lateral or supine positioning with head elevation is preferred.

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Correct Answer is ["A","C"]

Explanation

A. Distended neck veins is correct because during the oliguric phase of AKI, the kidneys are unable to excrete adequate amounts of fluid. This leads to volume overload, which increases central venous pressure. One of the most visible signs of this is jugular venous distension (JVD), indicating that the heart is under increased preload stress due to retained fluid. This can also be an early indicator of potential complications such as pulmonary congestion or heart failure.

B. Hypotension is incorrect because fluid overload usually results in hypertension, not hypotension. Blood pressure rises as the circulating volume increases, which can further compromise kidney function and exacerbate cardiac stress. Hypotension is more characteristic of pre-renal AKI, which is often caused by hypovolemia or decreased perfusion to the kidneys.

C. Edema is correct because impaired renal excretion during the oliguric phase causes fluid retention, leading to accumulation in the interstitial spaces. This is commonly observed as peripheral edemain the legs and feet, sacral edemain bedridden patients, and in severe cases, pulmonary edema, which can present with dyspnea and crackles on auscultation. Edema is a hallmark clinical finding in patients with AKI and fluid overload.

D. Fever is incorrect because it is not a direct symptom of fluid overload. While fever may occur if there is a concurrent infection (which can contribute to AKI), it is not a defining characteristic of the oliguric phase.

A. APD requires manual exchanges during the day B. APD cannot achieve adequate solute clearance C. APD is typically performed while the patient sleeps D. APD uses a lower volume of dialysate than manual PD

Correct Answer is C

Explanation

A. APD requires manual exchanges during the day is incorrect because APD is automated, using a cycler machine to perform exchanges overnight, reducing the need for manual daytime exchanges. Some patients may also perform a daytime dwell, but it is not a requirementof APD.

B. APD cannot achieve adequate solute clearance is incorrect because APD can achieve adequate solute and fluid clearancewhen properly prescribed. The cycler controls the number of exchanges, dwell times, and volume, making it an effective alternative to continuous ambulatory peritoneal dialysis (CAPD).

C. APD is typically performed while the patient sleeps is correct. Automated peritoneal dialysis uses a cycler machine overnightto perform multiple exchanges, allowing the patient to remain free during the day. This provides convenience, improves quality of life, and maintains effective dialysis clearance.

D. APD uses a lower volume of dialysate than manual PD is incorrect because APD often uses larger volumes per exchangethan continuous ambulatory PD (CAPD), especially for patients requiring higher ultrafiltration. The cycler allows precise control of volume and timing.

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Which of the following are nursing interventions related to body positioning when caring for a patient with increased ICP?

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Naxlex Comprehensive Predictor Exams

During the Oliguric phase of acute kidney injury, which of the following symptoms would you expect in a patient with fluid overload?

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Correct Answer is C

Explanation

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