The nurse is caring for a client who sustained a head injury in a motor vehicle accident and is diagnosed with a subdural hematoma and increased intracranial pressure. Which nursing intervention is appropriate for this client?
Keeping the room brightly lit.
Encouraging coughing and deep breathing exercises.
Placing the client in a supine position.
Implementing seizure precautions.
The Correct Answer is D
A. Keeping the room brightly lit can be overstimulating and may increase ICP; therefore, a calm, dimly lit environment is preferable.
B. Encouraging coughing and deep breathing exercises could increase ICP and should be avoided unless specifically indicated.
C. Placing the client in a supine position is not recommended for clients with increased ICP; they should typically be positioned with the head elevated to promote venous drainage.
D. Implementing seizure precautions is critical as head injuries can lead to seizures, and ensuring the client's safety is a priority.
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Correct Answer is A
Explanation
A. In SIADH, excess ADH causes water retention and hyponatremia; fluid restriction helps to prevent further dilution of sodium and manage fluid balance.
B. NPO status is unnecessary unless otherwise indicated; managing fluid intake is more effective.
C. Increasing oral intake would worsen fluid overload and hyponatremia.
D. Rapid IV fluid infusion can exacerbate the client’s condition by increasing fluid volume further.
Correct Answer is A
Explanation
A. Hypertension with bradycardia is characteristic of autonomic dysreflexia due to the exaggerated sympathetic response causing increased blood pressure while the body compensates with bradycardia.
B. Hypotension with tachycardia is not indicative of autonomic dysreflexia; instead, it suggests different underlying issues.
C. While hypertension can occur in autonomic dysreflexia, it is typically accompanied by bradycardia, not tachycardia.
D. Hypotension with bradycardia does not correlate with autonomic dysreflexia and suggests other health complications.