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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View Related questions
Correct Answer is ["A","B","C","D","E"]
Explanation
A. Edema of the ear canal is a common symptom of external otitis, indicating inflammation and infection in the area.
B. Purulent drainage from the ear canal often signifies bacterial infection and is a key symptom to monitor.
C. Burning in the ear canal can occur due to inflammation and is a common complaint in external otitis.
D. Pain when moving the auricle is a classic symptom of external otitis, indicating irritation or inflammation of the external ear.
E. Tenderness of the external ear is a common finding in external otitis and should be monitored as it indicates inflammation and potential infection.
Correct Answer is B
Explanation
A. The Glasgow Coma Scale is useful for assessing consciousness levels but may not be as sensitive for changes in brainstem function in a patient already in an induced coma.
B. Assessing pupillary size and reaction provides critical information on brainstem function and can indicate changes in ICP. Changes in pupil size and reaction can signify worsening cerebral function or brain herniation.
C. Blood pressure and heart rate are vital signs that can suggest increased ICP, but they are not as direct an indicator of cerebral function as pupil assessment.
D. The gag reflex is important but does not provide as direct information about cerebral function related to ICP as pupillary assessment does.