A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take?
Use log rolling to reposition the client.
Place a warming blanket on the client.
Instruct the client to cough and deep breathe.
Place the client in a supine position.
The Correct Answer is A
Choice A Reason: This is correct because using log rolling to reposition the client helps maintain the alignment of the head and neck, which prevents further increases in ICP.
Choice B Reason: This is incorrect because placing a warming blanket on the client can cause vasodilation and increase cerebral blood flow, which can raise ICP.
Choice C Reason: This is incorrect because instructing the client to cough and deep breathe can increase intrathoracic pressure and impede venous return, which can elevate ICP.
Choice D Reason: This is incorrect because placing the client in a supine position can decrease cerebral perfusion pressure and increase ICP. The client should be placed in a semi-Fowler's position with the head elevated at 30 degrees.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: This choice is correct because allowing the drainage to drip onto a sterile gauze pad may help to identify if it is cerebrospinal fluid (CSF), which is a clear fluid that surrounds and protects the brain and spinal cord. CSF leakage from the nose (rhinorrhea) may indicate a basilar skull fracture, which is a serious injury that can cause intracranial bleeding, infection, or brain damage. The nurse should test the drainage for the presence of glucose or the halo sign, which are indicators of CSF.
Choice B Reason: This choice is incorrect because obtaining a culture of the specimen using sterile swabs may introduce bacteria into the nasal cavity and increase the risk of infection. The nurse should avoid inserting anything into the nose or mouth of a client who has a suspected basilar skull fracture.
Choice C Reason: This choice is incorrect because inserting sterile packing into the nares may increase the pressure in the cranial cavity and worsen the injury. The nurse should avoid applying pressure or occluding the nose or ears of a client who has a suspected basilar skull fracture.
Choice D Reason: This choice is incorrect because suctioning the nose gently with a bulb syringe may damage the nasal mucosa and cause bleeding. The nurse should avoid suctioning or irrigating the nose or ears of a client who has a suspected basilar skull fracture.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because a pneumothorax is a condition in which air enters the pleural space and causes the lung to collapse. It does not cause the chest wall to move inward and outward paradoxically.
Choice B Reason: This is incorrect because atelectasis is a condition in which alveoli collapse and cause reduced gas exchange. It does not cause the chest wall to move inward and outward paradoxically.
Choice C Reason: This is correct because flail chest is a condition in which multiple ribs are fractured and cause a segment of the chest wall to detach from the rest of the thoracic cage. It causes the chest wall to move inward and outward paradoxically, as well as dyspnea and pain.
Choice D Reason: This is incorrect because a hemothorax is a condition in which blood enters the pleural space and causes the lung to collapse. It does not cause the chest wall to move inward and outward paradoxically.
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