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)?
Limit suctioning the client's airway to 30 seconds at a time
Group several nursing activities to be completed at one time
Flex the client's neck forward
Place the client in a quiet environment
The Correct Answer is D
Place the client in a quiet environment.
- A. 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.
- 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. 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.
- 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 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.
Correct Answer is B
Explanation
Choice A rationale:
While providing end-of-life education is important, it is not a specific requirement under the Patient Self-Determination Act. The act primarily focuses on ensuring that patients' wishes regarding medical treatment and interventions are respected through advance directives.
Choice B rationale:
Documenting in the client's medical record if the client has advance directives is a requirement under the Patient Self-Determination Act. This documentation ensures that healthcare providers are aware of the patient's preferences regarding medical treatment, especially in end-of-life situations. Advance directives may include living wills or durable power of attorney for healthcare, allowing patients to express their choices regarding medical interventions and appointing someone to make decisions on their behalf if they are unable to do so.
Choice C rationale:
Providing the client with a list of eligible individuals who can serve as a health care proxy is not a requirement under the Patient Self-Determination Act. While it can be helpful, the act primarily emphasizes documenting and respecting the patient's existing advance directives.
Choice D rationale:
Ensuring the client has an attorney for assistance with end-of-life documents is not a requirement under the Patient Self-Determination Act. While legal advice can be beneficial, the act primarily focuses on healthcare providers' responsibilities in documenting and respecting patients' advance directives.
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