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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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:

A. Provide the client with a stool softener: Clients with thrombocytopenia are at increased risk for bleeding, including gastrointestinal bleeding. Hard stools can cause straining during defecation, which may lead to rectal bleeding. Administering a stool softener helps prevent constipation and reduces the risk of bleeding from the gastrointestinal tract.

B. Remove fresh flowers from the client's room: This intervention is appropriate for clients who are immunocompromised to prevent infection, but it is not specifically necessary for thrombocytopenia unless the client also has neutropenia. The main concern in thrombocytopenia is bleeding, not infection.

C. Avoid serving the client raw vegetables: While raw vegetables may carry a risk of infection, thrombocytopenia alone does not require dietary restrictions for raw vegetables. Safe food handling is important, but preventing bleeding is the primary focus of care.

D. Encourage the client to floss daily: Flossing can increase the risk of gum bleeding in clients with thrombocytopenia. Oral hygiene should be maintained gently with soft-bristled toothbrushes, but daily flossing is not recommended because it may cause unnecessary bleeding.

A. Provide information about stress management. B. Administer epinephrine for acute episodes. C. Maintain a cool temperature in the client's room. D. Give a glucocorticoid steroid twice per day.

Correct Answer is A

Explanation

Rationale:

A. Provide information about stress management.: Stress is a major trigger for vasospastic episodes in Raynaud’s disease because it increases sympathetic nervous system activity, causing further arterial constriction. Stress-reduction techniques such as deep breathing, biofeedback, or relaxation exercises helps reduce the frequency and severity of attacks.

B. Administer epinephrine for acute episodes.: Epinephrine causes vasoconstriction, which would worsen Raynaud’s symptoms by further reducing blood flow to the extremities. During an acute episode, warming the affected areas and avoiding additional vasoconstrictors is essential. Epinephrine is not indicated as a treatment and can intensify ischemic discomfort

C. Maintain a cool temperature in the client's room.: Cold temperatures are one of the most common triggers for vasospasm in Raynaud’s disease. A cool environment increase the likelihood of an episode by promoting peripheral vasoconstriction. The nurse should provide a warm environment and encourage protective clothing to maintain circulation.

D. Give a glucocorticoid steroid twice per day.: Steroids are not a standard treatment for Raynaud’s because the condition is related to vasospasm rather than inflammatory processes. Routine steroid use would expose the client to unnecessary adverse effects without addressing the underlying problem. Management strategies focus instead on warmth, lifestyle modification, and vasodilator medications when needed.

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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

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has thrombocytopenia. Which of the following actions should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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