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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

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A rationale:

Massaging the legs before applying the stockings is not advisable. Vigorous massage can dislodge clots in patients with DVT, leading to serious complications like pulmonary embolism. It is essential to handle the legs gently and follow the proper procedure for applying antiembolitic stockings.

Choice B rationale:

Folding the stockings at the top if they are too long is not recommended. Altering the stockings in this way can create uneven pressure, reducing their effectiveness in preventing DVT. It is crucial to choose the correct size of stockings to ensure proper compression and prevention of complications.

Choice C rationale:

Measuring the legs with a tape measure to determine the stocking size is the correct action. Proper sizing is essential to ensure the stockings fit the patient correctly and provide the appropriate level of compression. Ill-fitting stockings can be ineffective and may even cause harm, such as skin abrasions or impeded circulation.

Choice D rationale:

Removing the stockings every 24 hours is unnecessary unless there is a specific medical indication to do so. Continuous wear of antiembolitic stockings is generally recommended to provide consistent compression and prevent deep-vein thrombosis (DVT)

A. Administer a dose of terbutaline to the client. B. Place the client in a warm bath. C. Apply counterpressure during each contraction. D. Request the provider prescribe a pudendal nerve block.

Correct Answer is C

Explanation

Choice A rationale:

Administering terbutaline is used to stop or slow down preterm labor contractions. In the given scenario, the client is in the latent phase of labor and is experiencing severe back pain. Terbutaline is not indicated for back pain during labor.

Choice B rationale:

Placing the client in a warm bath can provide comfort and relaxation, but it may not specifically alleviate back pain during labor. Additionally, warm baths are more commonly used for pain relief in early labor or during the active phase, not specifically for back pain.

Choice C rationale:

Applying counterpressure during each contraction is an appropriate intervention for relieving back pain during labor. Back pain is a common discomfort experienced by many women during labor, and counterpressure, often applied by a support person or nurse, can help alleviate the discomfort. It is a non-pharmacological method that can be effective in managing pain during labor.

Choice D rationale:

Requesting the provider prescribe a pudendal nerve block is not the first-line intervention for back pain during labor. Pudendal nerve blocks are used for pain relief during the second stage of labor (during delivery) and are typically administered by the provider if needed. It is not the appropriate intervention for back pain in the latent phase of labor.

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who is in the latent phase of labor and reports severe back pain.The vaginal examination reveals that the cervix is dilated 2 cm, 25% effaced, and -2 station.Which of the following interventions should the nurse implement?

Correct Answer is C

Explanation

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