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. Encouraging fluid intake at and between meals helps to dilute urine and can reduce the risk of urinary tract infections (UTIs) by promoting regular urination.
B. Cleansing the perineum should be done from front to back to prevent the introduction of bacteria from the rectal area to the urethra, so this option is incorrect.
C. Offering the bedpan every 2 hours may not be sufficient for individuals at risk for UTIs, as more frequent voiding can help prevent infection.
D. An indwelling urinary catheter increases the risk of urinary tract infections and should be avoided unless absolutely necessary; intermittent catheterization is generally preferred for those with spinal cord injuries to minimize this risk.
Correct Answer is C
Explanation
A. While chlorine can kill some bacteria, it does not prevent all microbial growth and does not directly explain ear infections.
B. Pool water entering the Eustachian tubes is unlikely; infections are more commonly related to pathogens in the water.
C. The best response addresses the presence of microorganisms in pool water that can enter the ear and potentially lead to infections, such as swimmer's ear (otitis externa).
D. Pool water is not typically associated with drying out the ears; rather, it can lead to excess moisture, which can promote bacterial growth.