A nurse is caring for a client who experienced a traumatic brain injury 72 hr ago.
Which of the following findings should the nurse identify as a potential indication of increased intracranial pressure?

 

The correct answer is: b. “Tighten your muscles before relaxing them when using muscle relaxation techniques.”

Rationale for Choice B: Progressive Muscle Relaxation (PMR) is a well-established technique used in stress management and relaxation therapy. It involves systematically tensing and then relaxing specific muscle groups throughout the body. By tensing the muscles first, individuals can become more aware of the contrast between tension and relaxation, thereby enhancing the relaxation response. This heightened awareness helps individuals recognize and release muscular tension more effectively, leading to deeper relaxation and stress relief.

Rationale for Choice A: Choice A suggests talking to someone admired as the first step in using mindfulness techniques to relax. However, mindfulness practices typically involve cultivating awareness of the present moment without judgment. While seeking support from others may be beneficial for stress management, it is not a foundational aspect of mindfulness practice. Mindfulness often entails individual introspection and observation of one's thoughts, feelings, and bodily sensations.

Rationale for Choice C: Choice C recommends breathing in through the mouth and out through the nose during deep breathing exercises. While there are various breathing techniques utilized in stress management, the typical recommendation for deep breathing exercises is to inhale through the nose and exhale through the mouth. Nasal breathing helps regulate the flow of air, optimizes oxygen exchange, and activates the parasympathetic nervous system, promoting relaxation and stress reduction.

Rationale for Choice D: Choice D proposes imagining a stimulating situation when practicing guided imagery. However, guided imagery is a relaxation technique that involves creating vivid mental images of calming and tranquil scenes, such as a serene beach or peaceful forest. The purpose of guided imagery is to evoke positive emotions, reduce stress, and induce a state of deep relaxation. Imagining stimulating situations may have the opposite effect, potentially increasing arousal and tension rather than promoting relaxation.

In summary, while all choices may have some relevance to stress management, Choice B is the most appropriate as it aligns with the established technique of Progressive Muscle Relaxation. Choices A, C, and D deviate from widely recognized relaxation methods and are therefore considered incorrect in this context.

Choice A rationale:

Taking antibiotics when having a virus is not a correct understanding of infection prevention. Antibiotics are ineffective against viruses and should only be used for bacterial infections under the guidance of a healthcare provider. This statement indicates a misunderstanding of infection prevention.

Choice B rationale:

Washing hands for at least 20 seconds with soap and water is the recommended practice for infection prevention. Washing hands for 10 seconds may not be sufficient to remove all germs effectively. This statement does not demonstrate a proper understanding of hand hygiene.

Choice C rationale:

Cleaning a cat's litter box during pregnancy is not recommended due to the risk of contracting toxoplasmosis, a parasitic infection that can harm the fetus. Pregnant individuals should avoid handling cat litter to prevent exposure to this infection. This statement indicates a lack of awareness regarding infection prevention during pregnancy.

Choice D rationale:

Waiting 5 days after the chickenpox sores have crusted before visiting a person with chickenpox demonstrates an understanding of infection prevention. Chickenpox is highly contagious, and individuals should avoid close contact until the sores have fully healed and crusted over. This statement reflects appropriate knowledge about preventing the spread of contagious diseases during pregnancy.