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 B
Explanation
- A is incorrect because diarrhea is not an adverse effect of clonidine, but rather a symptom of other conditions such as infection, inflammation, or food intolerance.
- B is correct because dry mouth is a common adverse effect of clonidine, which is an alpha-2 adrenergic agonist that reduces sympathetic nervous system activity.
- C is incorrect because photophobia, or sensitivity to light, is not an adverse effect of clonidine, but rather a symptom of other conditions such as migraine, eye injury, or infection.
- D is incorrect because bruising, or bleeding under the skin, is not an adverse effect of clonidine, but rather a symptom of other conditions such as coagulation disorders, vitamin deficiency, or trauma.
Correct Answer is C
Explanation
"How does this make you feel?"
- A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
- B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
- C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
- D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.
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