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 D
Explanation
A. Exophthalmos is typically associated with hyperthyroidism (specifically Graves' disease) rather than hypothyroidism.
B. Diaphoresis (excessive sweating) is also more common in hyperthyroid states, not hypothyroidism.
C. Palpitations are indicative of an increased metabolic rate, which is common in hyperthyroidism; therefore, they would not be expected in a client with hypothyroidism.
D. Lethargy is a classic symptom of hypothyroidism due to decreased metabolism, leading to fatigue and reduced energy levels, making it the expected finding.
Correct Answer is D
Explanation
A. Encouraging deep breathing exercises may help with respiratory function but does not address the immediate risks associated with increased ICP.
B. Elevating the head of the bed can help reduce ICP; however, the priority intervention is to closely monitor ICP to identify any changes in the client's condition.
C. Administering a sedative may be appropriate, but it is not as critical as monitoring ICP in a client with Cushing's Triad, where altered consciousness and respiratory changes may be present.
D. Monitoring ICP is crucial in this situation, as Cushing's Triad indicates a potential increase in ICP, and timely interventions can prevent further complications.