The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)
Encourage the patient to cough to expectorate secretions
Elevate the head of the bed to 30-45 degrees
Stimulate the patient with active range of motion exercises
Perform serial neurologic assessments while hospitalized
Contact the healthcare provider if the ICP is sustained between 30-40mmHg
Correct Answer : B,D,E
A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.
B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.
C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.
D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.
E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications.
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Correct Answer is C
Explanation
A. Soft restraints are not recommended during a seizure and can cause harm to the patient.
B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.
C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.
D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.
Correct Answer is B
Explanation
A. A hearing test does not address the infection symptoms and would not be the priority.
B. Obtaining a culture of the drainage is necessary to identify any infection and guide appropriate antibiotic treatment.
C. Removing a foreign body may not be relevant and could worsen infection symptoms if not necessary.
D. A CT scan may be needed if further complications are suspected, but it is not the priority for infection symptoms.