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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

Metoprolol decreases cardiac workload by reducing heart rate and myocardial oxygen demand. A heart rate of 62 is within normal limits, demonstrating effective beta-blocker action and improved cardiac efficiency.

Choice B rationale

Lying flat without difficulty breathing reflects improved respiratory status, which is more related to pulmonary management, not directly indicative of reduced cardiac workload or beta-blocker efficacy.

Choice C rationale

Absence of dyspnea after climbing stairs suggests improved physical fitness but does not directly measure the cardiac effects of metoprolol, which targets heart rate reduction and myocardial oxygen use.

Choice D rationale

Weight loss is related to overall health improvement or dietary changes rather than specific effects of metoprolol, which primarily impacts heart rate and cardiac oxygen consumption.

A. Hold the feeding if the client has soft brown stools and is passing flatus. B. Dilute each medication with 5% dextrose in water (D5W) and flush with at least 30 mL. C. Discuss the order with the prescriber if the client's abdomen is distended with hypoactive bowel sounds and RLQ tenderness. D. Check for residual enteral formula prior to administration.

Correct Answer is C

Explanation

Choice A rationale

Soft stools and flatus indicate proper gastrointestinal function, suggesting tolerance to feeding. With no adverse symptoms, it is not scientifically valid to hold enteral feeding based on these findings alone.

Choice B rationale

Diluting medications with D5W and flushing ensures patency but does not address potential complications like abdominal distention or bowel sounds. RLQ tenderness must first be evaluated for safety.

Choice C rationale

Abdomen distention with hypoactive bowel sounds and RLQ tenderness suggests possible ileus or bowel obstruction. Discussing this condition with the prescriber ensures safe feeding practices and prevents worsening complications.

Choice D rationale

Residual formula checks are relevant for gastric, not jejunostomy, feeding. Scientific practice discourages assessing residual in jejunostomy feeding as the tube bypasses the stomach.

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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?

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Correct Answer is C

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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?