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 C
Explanation
A. The supine position can increase ICP and is not recommended for clients with elevated ICP.
B. Instructing the client to pull themselves up may increase ICP due to straining.
C. Log rolling helps maintain spinal alignment and minimizes abrupt head movement, which is essential in managing ICP.
D. Sitting with legs dangling may cause a sudden shift in intracranial pressure and is not advised for these clients.
Correct Answer is A
Explanation
A. Chvostek's sign, a facial muscle spasm upon tapping, is a clinical indicator of hypocalcemia, often caused by accidental removal or damage to the parathyroid glands during thyroid surgery.
B. Hypercalcemia does not typically cause a positive Chvostek’s sign.
C. Hypokalemia affects muscle and cardiac function but does not result in a positive Chvostek’s sign.
D. Hyponatremia does not produce Chvostek's sign, which is specific to hypocalcemia.