A nurse is caring for a patient in the ICU with a diagnosis of an acute closed head injury whose intracranial pressure (ICP) is 25 mmHg.
What is the priority action by the nurse?
Continue with assessment and document findings.
Suction the patient to minimize secretions.
Notify the physician and raise the head of the bed 35–45 degrees.
Lower the head of the bed and pad the side rails.
The Correct Answer is C
Choice A rationale
Monitoring and documenting findings without intervention ignores the critical need to manage intracranial pressure (ICP). Normal ICP is 7-15 mmHg, and 25 mmHg indicates a dangerous elevation requiring prompt corrective actions.
Choice B rationale
Suctioning can trigger a vagal response, further increasing ICP. Interventions should aim to decrease ICP, not exacerbate it. Careful suctioning is used when airway clearance is critical, not as a routine measure.
Choice C rationale
Raising the head of the bed to 35–45 degrees promotes venous drainage, reducing ICP. Alerting the physician ensures timely medical interventions. This is the primary recommended action for elevated ICP cases.
Choice D rationale
Lowering the head of the bed can worsen ICP by impairing venous outflow. Padded side rails are useful for seizure precautions but are irrelevant for managing elevated ICP in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Administering 40 ounces of fruit juice would result in excessive carbohydrate intake and is inappropriate for treating hypoglycemia. Standard treatment includes 15 grams of carbohydrates or intravenous glucose for severe symptoms.
Choice B rationale
Hard candy provides 15 grams of carbohydrates, suitable for a patient who is alert and able to safely swallow. However, this client exhibits confusion and lethargy, necessitating a quicker, safer IV intervention.
Choice C rationale
Administering Dextrose 50% IV push rapidly raises blood glucose levels, effectively treating hypoglycemia in symptomatic, confused, or unconscious patients. This intervention bypasses the gastrointestinal tract for immediate action.
Choice D rationale
Rechecking glucose after 15 minutes is essential after treatment but does not address acute hypoglycemia. Delaying treatment risks prolonged hypoglycemia, increasing the risk of neuronal injury or further clinical deterioration. .
Correct Answer is ["66.7"]
Explanation
Step 1 is (1600 mL ÷ 24 hours).
Answer is 66.7 mL/hr.
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