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 ["A","B","C","D"]
Explanation
- A: Correct. Firmly massaging the uterine fundus helps to contract the uterus and reduce bleeding.
- B: Correct. Providing emotional support helps to calm the client and reduce anxiety, which can worsen bleeding.
- C: Correct. Administering oxygen helps to improve tissue perfusion and oxygenation, which can be compromised by blood loss. Weighing the perineal pads helps to quantify the amount of blood loss and monitor for hemorrhage.
- D: Correct. Inserting an indwelling urinary catheter helps to empty the bladder and allow the uterus to descend and contract more effectively. Administering methylergonovine helps to stimulate uterine contractions and control bleeding.
- E: Incorrect. Administering terbutaline is contraindicated in this situation, as it relaxes the uterine smooth muscle and increases bleeding.
Correct Answer is A
Explanation
A: The Agency for Healthcare Research and Quality is a federal agency that conducts research on health care quality, access, and outcomes. It provides specific data on migrant farmworkers.
B: The National Institutes of Health is a federal agency that supports biomedical and behavioral research. It does not provide specific data on migrant farmworkers.
C: The Department of Agriculture is a federal agency that oversees agricultural production, food safety, nutrition, and rural development. It does not collects comprehensivedata on migrant and seasonal farmworkers, such as their demographics, health status, and access to health care.
D: The World Health Organization is an international organization that works to improve global health and coordinate responses to health emergencies. It does not provide specific data on migrant farmworkers in the United States.
Answer is:Department of Agriculture. The Department of Agriculture is a federal agency that oversees agricultural production, food safety, nutrition, and rural development.It also collects and publishes data on migrant and seasonal farmworkers, such as their demographics, health status, and access to health care1.
Statement is wrong because: Agency for Healthcare Research and Quality (AHRQ) is an independent agency within the U.S.Department of Health and Human Services that conducts research to improve the quality, safety, efficiency, and effectiveness of health care2.National Institutes of Health (NIH) is a federal agency that supports biomedical research and public health initiatives3. World Health Organization (WHO) is a specialized agency of the United Nations that is concerned with international public health.
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