You are an ICU nurse caring for a patient who has been having intermittent increases in their intracranial pressure (ICP). What are the measures that you as the RN can implement to try and decrease the patient's ICP? < Select all that apply>
Encourage the entire family to visit in case the patient expires.
Keep the patient's neck midline and neutral.
Administer stool softeners.
Keep the room curtains open to maximize natural light.
Keep head of bed (HOB) at 30 degrees.
Correct Answer : B,C,E
Choice A rationale
Encouraging extensive family visitation in the context of impending demise, while emotionally supportive, does not directly address the physiological mechanisms of intracranial pressure reduction. Increased stimulation and emotional distress can paradoxically elevate ICP by increasing cerebral metabolic demand and blood flow, which is counterproductive to managing an acute neurological crisis.
Choice B rationale
Maintaining the patient's neck in a midline and neutral position is crucial to facilitate optimal venous outflow from the brain. Compression or kinking of the jugular veins due to neck rotation or flexion can impede cerebral venous drainage, leading to an increase in cerebral blood volume and subsequently elevated intracranial pressure.
Choice C rationale
Administering stool softeners helps prevent straining during defecation, a maneuver known as the Valsalva maneuver. The Valsalva maneuver increases intrathoracic and intra-abdominal pressure, which in turn transiently increases central venous pressure and impedes cerebral venous outflow, thereby elevating intracranial pressure.
Choice D rationale
Keeping room curtains open to maximize natural light can increase environmental stimulation, potentially leading to increased cerebral activity and metabolic demand. This heightened activity can result in increased cerebral blood flow and volume, which can contribute to elevated intracranial pressure in a neurologically compromised patient.
Choice E rationale
Elevating the head of the bed (HOB) to 30 degrees promotes venous drainage from the brain by utilizing gravity. This position helps to reduce cerebral blood volume, thereby decreasing intracranial pressure. It also aids in preventing aspiration while maintaining cerebral perfusion pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Obtaining informed consent is a fundamental ethical and legal requirement before any invasive medical procedure, including a bronchoscopy. This ensures patient autonomy, allowing them to make an educated decision based on understanding the procedure's risks, benefits, and alternatives. The patient's signature indicates their voluntary agreement after a thorough discussion with the healthcare provider, demonstrating adherence to patient rights.
Choice B rationale
Flumazenil is a benzodiazepine receptor antagonist used to reverse the sedative effects of benzodiazepines. While benzodiazepines like midazolam are commonly used for conscious sedation during bronchoscopy, flumazenil is generally not kept readily available for routine use. It is an emergency reversal agent reserved for severe respiratory depression or over-sedation.
Choice C rationale
Ensuring the client is NPO (nil per os) for at least 6 hours prior to a bronchoscopy is crucial to prevent aspiration. The procedure involves manipulating the airway, which can stimulate the gag reflex and potentially lead to regurgitation of gastric contents into the lungs, causing aspiration pneumonia or acute respiratory distress. Fasting significantly reduces this risk.
Choice D rationale
Continuous monitoring of heart rate and oxygen saturation via a bedside heart monitor and pulse oximeter is essential during and after a bronchoscopy. This allows for immediate detection of adverse events such as hypoxemia, arrhythmias, or respiratory depression, enabling prompt intervention. Constant vigilance ensures patient safety throughout the procedure.
Choice E rationale
Midazolam, a short-acting benzodiazepine, is commonly used for conscious sedation during bronchoscopy. Its anxiolytic, sedative, and amnestic properties help to reduce patient anxiety, promote comfort, and minimize recall of the procedure. Its rapid onset and short duration of action make it suitable for outpatient procedures.
Correct Answer is B
Explanation
Choice A rationale
Uncompensated respiratory acidosis would exhibit a low pH (normal range 7.35-7.45) and an elevated PaCO2 (normal range 35-45 mmHg), with a bicarbonate level (normal range 22-26 mEq/L) that remains within the normal range. In this scenario, the bicarbonate is elevated, indicating a renal compensatory response has begun.
Choice B rationale
The patient's pH of 7.3 indicates acidosis (normal 7.35-7.45). The PaCO2 of 68 mmHg is elevated (normal 35-45 mmHg), indicating a respiratory origin. The HCO3 of 28 mmol/L is elevated (normal 22-26 mEq/L), signifying that the kidneys are attempting to compensate by retaining bicarbonate. Since the pH is still acidic, but the bicarbonate is responding, it is partially compensated respiratory acidosis.
Choice C rationale
Metabolic acidosis is characterized by a low pH (normal 7.35-7.45) and a low bicarbonate level (normal 22-26 mEq/L). The PaCO2 (normal 35-45 mmHg) would either be normal if uncompensated or low if the respiratory system was compensating. Here, the primary disturbance is respiratory.
Choice D rationale
Metabolic alkalosis presents with an elevated pH (normal 7.35-7.45) and an elevated bicarbonate level (normal 22-26 mEq/L). The PaCO2 (normal 35-45 mmHg) would be normal if uncompensated or elevated if the respiratory system was compensating. This patient's pH is acidic, ruling out alkalosis.
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