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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
- A. Constipation is not a common complication of vacuum-assisted birth. It may be related to other factors such as dehydration, opioid use, or decreased mobility.
- B. Urinary urgency is not a common complication of vacuum-assisted birth. It may be related to other factors such as bladder trauma, infection, or diuretic use.
- C. Cervical laceration is a common complication of vacuum-assisted birth. It occurs when the vacuum cup causes damage to the cervix during delivery. It can lead to bleeding, infection, or cervical incompetence in future pregnancies.
- D. Retained placenta is not a common complication of vacuum-assisted birth. It may be related to other factors such as placenta accreta, uterine atony, or manual removal of the placenta.
Correct Answer is D
Explanation
Choice Arationale:
Allowing the client to eat meals in his room might not be the best approach. Patients with anorexia nervosa often have distorted body image and may engage in secretive behaviors related to food intake. Supervised meals and observation during and after meals are essential to prevent behaviors like purging.
Choice B rationale:
Weighing the client every 48 hours is not frequent enough for a patient with anorexia nervosa. Daily weight monitoring is crucial in these cases because rapid weight loss or fluctuations can indicate worsening malnutrition, dehydration, or other medical complications.
Choice Crationale:
Obtaining vital signs every other day might not provide an accurate picture of the client's overall health status, especially during the critical early phase of care. In anorexia nervosa, patients are at risk of severe complications such as electrolyte imbalances, cardiac issues, and malnutrition, which can rapidly change and require close monitoring.
Choice D rationale:
Observing the client for 1 hour after meals is a crucial nursing intervention for individuals with anorexia nervosa. After meals, these patients are at risk of engaging in purging behaviors like vomiting or excessive exercise to compensate for caloric intake. Close observation can help prevent these behaviors and ensure the client's safety.
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