A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

Suction the client every 2 hr.

Maintain ICP at 20 mm Hg

Avoid overstimulation of the client.

Keep the client in a supine position.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Suction the client every 2 hr: Frequent suctioning can increase intracranial pressure due to stimulation of the airway and coughing reflex. Suctioning should be performed only when necessary and with careful monitoring of ICP, rather than routinely every 2 hours.

B. Maintain ICP at 20 mm Hg: Normal ICP ranges from 5 to 15 mm Hg. An ICP of 20 mm Hg or higher indicates increased intracranial pressure and requires intervention. Planning to maintain ICP at this elevated level is unsafe and not appropriate for care planning.

C. Avoid overstimulation of the client: Minimizing noise, unnecessary procedures, and environmental stimuli helps prevent spikes in ICP. Overstimulation can increase cerebral metabolic demand and worsen intracranial hypertension, so this intervention supports ICP management and neurologic stability.

D. Keep the client in a supine position: Supine positioning can impair venous drainage from the brain, potentially increasing ICP. Elevating the head of the bed to 30 degrees while maintaining spinal precautions is preferred to promote venous outflow and reduce intracranial pressure.

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Correct Answer is ["B","C"]

Explanation

Rationale:

A. Respite care: Respite care provides temporary relief for caregivers, but it does not directly assist clients with limited financial resources in obtaining home IV therapy or covering medical costs. This resource may be helpful later but is not a primary financial support option.

B. Food stamps: Supplemental Nutrition Assistance Program (SNAP), or food stamps, helps low-income clients access adequate nutrition. Proper nutrition is important for healing and overall health, making this a relevant resource for a client below the poverty level.

C. Medicaid: Medicaid provides health coverage for low-income individuals and can help cover costs associated with home IV therapy, medications, and other healthcare needs. It is an appropriate recommendation for a client who meets income eligibility criteria.

D. Medicare Part A: Medicare primarily covers inpatient hospital care, skilled nursing facilities, hospice, and some home health services for clients over 65 or with certain disabilities. A young adult below the poverty level may not qualify, making this less appropriate for the scenario.

E. Adult day care: Adult day care provides socialization and supervision during the day, mainly for older adults or those with cognitive impairments. It does not address financial assistance or coverage for home IV therapy, so it is not a primary resource in this case.

A. Administer the medication into the vastus lateralis muscle. B. Administer the medication with a 20-gauge needle. C. Administer the medication into the deltoid muscle. D. Administer the medication over 2 min.

Correct Answer is A

Explanation

Rationale:

A. Administer the medication into the vastus lateralis muscle: The vastus lateralis is the preferred site for intramuscular injections in infants because it is well-developed and free of major nerves and blood vessels. This site allows for safe and effective absorption of the medication.

B. Administer the medication with a 20-gauge needle: A 20-gauge needle is too large for infants and can cause unnecessary tissue trauma. A smaller gauge, typically 22–25, is appropriate for IM injections in infants to minimize pain and tissue damage.

C. Administer the medication into the deltoid muscle: The deltoid muscle is underdeveloped in infants, making it unsuitable for IM injections due to limited muscle mass and risk of injury to underlying structures. It is generally used only in older children or adults.

D. Administer the medication over 2 min: IM injections are typically administered at a moderate pace, but a 2-minute administration is unnecessarily slow for infants. Proper technique involves steady, controlled injection without causing excessive discomfort.

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A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

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Explanation

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Correct Answer is A

Explanation

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