Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)?

Sims'

Trendelenburg

Prone

Semi-fowler's

Answer and Explanation

The Correct Answer is D

A. Sims' position is primarily used for rectal exams and enemas, and does not specifically help reduce ICP.
B. Trendelenburg position (head lower than feet) can increase ICP and is contraindicated.
C. Prone position can increase intracranial pressure due to impaired venous drainage.
D. Semi-Fowler’s position (head elevated 30–45 degrees) promotes venous drainage from the brain, helping to reduce ICP and improve patient comfort.

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Correct Answer is ["A","B","E"]

Explanation

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.

A. Assess the client for bladder distention. B. Administer a nitrate antihypertensive. C. Place the client in a high-Fowler's position. D. Obtain the client's heart rate.

Correct Answer is C

Explanation

A. Bladder distention is a common trigger of autonomic dysreflexia, but the immediate priority is to reduce blood pressure by positioning the patient.
B. Antihypertensive medication may be necessary, but nonpharmacologic interventions such as positioning and removing the triggering stimulus should be done first.
C. Placing the client in a high-Fowler’s position is the first action to lower blood pressure by promoting venous pooling in the lower extremities, thereby reducing cerebral blood pressure and minimizing the risk of stroke.
D. Heart rate monitoring is part of the assessment but does not take priority over immediately addressing the dangerously high blood pressure.

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Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

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