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 B
Explanation
A. While hormones from the adrenal cortex do influence various metabolic processes, mineralocorticoids primarily focus on fluid and electrolyte balance rather than having major effects on all organs' metabolism.
B. Mineralocorticoids, such as aldosterone, play a crucial role in regulating fluid and electrolyte balance by promoting sodium retention and potassium excretion in the kidneys.
C. Regulation of carbohydrate and protein metabolism is mainly the function of glucocorticoids, not mineralocorticoids.
D. The release of ACTH is regulated by corticotropin-releasing hormone (CRH) from the hypothalamus, not directly influenced by mineralocorticoids.
Correct Answer is B
Explanation
A. Lowering the client's legs is not effective in managing autonomic dysreflexia and may not alleviate the cause of the high blood pressure.
B. Checking for a full bladder is the priority because bladder distension is a common trigger for autonomic dysreflexia in clients with spinal cord injuries, and relieving it can reduce the severe hypertensive response.
C. Antihypertensives may be used if non-pharmacological measures fail, but addressing the cause is the first action.
D. Pain medication is not indicated as the immediate intervention for autonomic dysreflexia, as the priority is identifying and removing the trigger.