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
A. Weight loss is not a common or serious adverse effect of valproic acid. Valproic acid can cause weight gain, not weight loss.
B. Jaundice is a sign of liver damage, which is a serious and potentially fatal adverse effect of valproic acid. Valproic acid can impair fatty acid metabolism and mitochondrial function, leading to hepatotoxicity and steatosis. The nurse should monitor the client's liver function tests and report any signs of jaundice, such as yellowing of the skin or eyes, dark urine, or clay-colored stools .
C. Bradycardia is not a common or serious adverse effect of valproic acid. Valproic acid can cause cardiac arrhythmias, but they are usually tachycardic, not bradycardic.
D. Polyuria is not a common or serious adverse effect of valproic acid. Valproic acid can cause hypernatremia and hypocalcemia, which can affect urine output, but polyuria is not a specific symptom of these electrolyte imbalances.
Correct Answer is A
Explanation
A. Correct. The nurse should turn off the CPM machine during mealtime to allow the client to eat comfortably and prevent aspiration.
B. Incorrect. The nurse should maintain the client's affected hip in a neutral position to prevent dislocation of the prosthesis and promote healing.
C. Incorrect. The nurse should not instruct the client how to adjust the CPM settings for comfort, as this could interfere with the prescribed range of motion and speed of the device. The nurse should notify the provider if the client reports discomfort or pain.
D. Incorrect. The nurse should not store the CPM machine under the client's bed when not in use, as this could pose a safety hazard and damage the device. The nurse should place the CPM machine on a stable surface away from the bed.
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