A nurse is caring for a client who is demonstrating signs of increasing intracranial pressure (ICP). The nurse recognizes that which nursing actions are indicated to decrease ICP?
Elevate the head of the bed to 30-45 degrees.
Administer intravenous fluids rapidly to increase intravascular volume.
Keep the client in a calm and quiet environment.
Administer morphine sulfate as prescribed for pain relief.
Allow the client to perform Valsalva maneuver.
Correct Answer : A,C,D
A. Elevating the head of the bed to 30-45 degrees helps facilitate venous drainage from the brain, thereby reducing ICP.
B. Administering intravenous fluids rapidly is not appropriate, as it can lead to fluid overload and increase ICP.
C. Keeping the client in a calm and quiet environment minimizes stimulation, which can contribute to increased ICP.
D. Administering morphine sulfate as prescribed can provide pain relief, which may help decrease ICP since pain can contribute to increased intracranial pressure.
E. The Valsalva maneuver increases intrathoracic pressure and can lead to increased ICP, making it contraindicated in this scenario.
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