A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?
Flex the client's neck forward.
Group several nursing activities to be completed at one time.
Limit suctioning the client's airway to 30 seconds at a time.
Place the client in a quiet environment.
The Correct Answer is D
A. Flexing the client's neck forward can increase intracranial pressure by impeding venous drainage from the brain and increasing cerebral blood volume. Therefore, this choice is incorrect.
B. Grouping several nursing activities to be completed at one time can increase intracranial pressure by stimulating the client and causing fluctuations in blood pressure and heart rate. Therefore, this choice is incorrect.
C. Limiting suctioning the client's airway to 30 seconds at a time can reduce intracranial pressure by minimizing hypoxia and hypercarbia, which can cause cerebral vasodilation and increased cerebral blood volume. However, this intervention alone is not sufficient to prevent increased intracranial pressure, and suctioning should be done only when necessary and with caution. Therefore, this choice is partially correct but not the best answer.
D. Placing the client in a quiet environment can reduce intracranial pressure by minimizing sensory stimulation and promoting relaxation, which can lower blood pressure and heart rate and decrease cerebral metabolic demand. Therefore, this choice is correct and the best answer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Pain with movement of the left great toe is incorrect finding: Pain may be expected in a client with a fractured left tibia, especially if the great toe is moved. Pain is more related to the fracture and may not specifically indicate altered tissue perfusion.
Choice B reason:
Faint pedal pulse of the left leg is correct because it indicates that the blood flow to the foot is diminished. The pedal pulse is the pulse felt on the top of the foot, and its faintness could suggest reduced arterial blood flow to the foot.
Choice C reason:
Warm skin temperature distal to the pin site is incorrect: Warm skin distal to the pin site may indicate adequate blood flow and could be a normal finding. Warmth is generally associated with increased blood flow to the area.
Choice D reason:
Purulent drainage at the pin site is incorrect. Purulent drainage at the pin site could indicate an infection, but it is not directly related to altered tissue perfusion. Infection can lead to complications, but it does not necessarily indicate reduced blood flow to the extremity
Correct Answer is C
Explanation
A. Incorrect. The nurse should educate the parent on the importance of nebulizer treatments to deliver medications that thin and loosen mucus in the airways.
B. Incorrect. The nurse should advise the parent to contact the provider if the child has a fever, which could indicate an infection or inflammation in the lungs.
C. Correct. The nurse should initiate a request for a high-frequency chest compression vest, which is a device that vibrates the chest wall and helps mobilize mucus from the lungs.
D. Incorrect. The nurse should encourage the parent to support the child's participation in team sports, which can improve lung function and social skills.
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