Which of these measures is appropriate for a patient diagnosed with increased intracranial pressure?

Suction every 2 hours.

Provide rest periods between nursing procedures.

Encourage active range of motion.

Assign the patient to a semiprivate room near the nurse's station.

Answer and Explanation

The Correct Answer is B

Choice A reason: Suctioning every 2 hours is not appropriate for a patient with increased intracranial pressure (ICP). Suctioning can increase ICP due to the stress and stimulation it causes. It should only be performed when absolutely necessary and with proper precautions to minimize ICP spikes.

Choice B reason: Providing rest periods between nursing procedures is the correct measure. This helps minimize stimulation and stress, which can increase ICP. Rest periods allow the patient to stabilize and reduce the risk of further increasing the pressure within the skull.

Choice C reason: Encouraging active range of motion exercises is not suitable for a patient with increased ICP. Physical activity can exacerbate the condition by increasing intracranial pressure. The focus should be on minimizing activity and stress to prevent further elevation of ICP.

Choice D reason: Assigning the patient to a semiprivate room near the nurse's station is not the best approach. Patients with increased ICP require a quiet and calm environment to help manage their condition. A semiprivate room near the nurse's station may expose the patient to more noise and activity, which could increase ICP.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: The regulation of water balance by the kidneys involves maintaining the appropriate volume and concentration of body fluids. By taking daily weights, nurses can assess fluid retention or loss, while monitoring intake and output (I&O) helps track fluid balance. Specific gravity measures the concentration of urine, which provides information about the kidneys' ability to concentrate or dilute urine. These interventions directly relate to the kidneys' role in regulating water balance.

Choice B reason: Regulation of acid-base balance by the kidneys involves maintaining the proper pH levels in the blood through excretion or retention of hydrogen ions and bicarbonate. While important, this function is not the primary focus of interventions like daily weights, I&O, and specific gravity monitoring, which are more related to water balance.

Choice C reason: The regulation of blood pressure by the kidneys is achieved through the renin-angiotensin-aldosterone system, which controls blood volume and systemic vascular resistance. Although fluid balance can indirectly affect blood pressure, the specific interventions mentioned are more directly related to water balance than blood pressure regulation.

Choice D reason: Regulation of metabolic wastes involves the kidneys filtering and excreting waste products from the blood. This function is vital for overall health, but interventions like daily weights, I&O, and specific gravity monitoring are more focused on assessing fluid balance rather than directly measuring waste elimination.

A. Effective pain management. B. Decrease patient anxiety. C. Adequate hydration achieved. D. Decrease potassium intake.

Correct Answer is A

Explanation

Choice A reason: Effective pain management is the highest priority in the care of a patient with acute pancreatitis. Severe abdominal pain is a hallmark of acute pancreatitis and can significantly impact the patient's comfort and ability to participate in other aspects of their care. Managing pain effectively helps improve the patient's overall well-being and allows for better participation in treatments and recovery.

Choice B reason: Decreasing patient anxiety is important, but it is not the primary goal in the acute management of pancreatitis. Addressing anxiety can help improve the patient's experience and adherence to treatment, but managing pain and hydration are more critical in the immediate care.

Choice C reason: Adequate hydration is crucial in the management of acute pancreatitis, as dehydration can worsen the condition and lead to complications. However, pain management takes precedence because uncontrolled pain can lead to further stress and complications, hindering the effectiveness of hydration and other treatments.

Choice D reason: Decreasing potassium intake is not a primary goal in the management of acute pancreatitis. While electrolyte balance is important, there is no direct indication that potassium levels need to be specifically managed unless there is a documented imbalance. The focus should be on pain management and hydration.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of these measures is appropriate for a patient diagnosed with increased intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Nursing interventions such as taking daily weights, I&O, and monitoring specific gravity relate to which kidney function?

Correct Answer is A

Explanation

In planning the care for a patient with acute pancreatitis, the nurse should make which of these goals the highest?

Correct Answer is A

Explanation

A nurse cares for a patient who is prescribed lactulose (Heptalac). The patient states, "I do not want to take this medication because it causes diarrhea." How would the nurse respond?

The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient's abdomen?

The client is receiving IV doses of Vancomycin every 12 hours. Which would be the nurse's priority to monitor for complications during the period that the patient is receiving this drug?

A patient has a traumatic brain injury. The nurse assesses the following: Pulse change from 82 to 60 beats/min, Pulse pressure increase from 26 to 40 mm Hg, and Respiratory irregularities. What action by the nurse takes priority?

To improve the oxygenation of a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position?

In a patient with septic shock, which complication will the nurse remain alert for?

The nurse is caring for a newly admitted patient with sepsis and has received orders from the physician. What order should the nurse implement first?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?