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 is correct because dopamine is a vasopressor that increases the contractility and stroke volume of the heart, which results in an increased systolic blood pressure.
Choice B Reason: This is incorrect because dopamine can cause tachycardia as a side effect, but this does not indicate a therapeutic effect. An increased radial heart rate can also indicate other conditions, such as anxiety, fever, or dehydration.
Choice C Reason: This is incorrect because dopamine does not reduce cardiac output, but rather increases it by improving the pumping function of the heart.
Choice D Reason: This is incorrect because dopamine does not reduce urine output, but rather increases it by stimulating the renal blood vessels and enhancing renal perfusion.
Correct Answer is A
Explanation
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.
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