A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

Maintain hyperventilation to a PaCO2 of 15 to 20mm Hg.

Routinely suction to prevent accumulation of respiratory secretions

Encourage visitation to prevent feelings of isolation.

Avoid positioning the client with neck and hip flexion.

Answer and Explanation

The Correct Answer is D

A. Maintain hyperventilation to a PaCO2 of 15 to 20 mm Hg. Hyperventilation can reduce ICP by causing vasoconstriction of cerebral blood vessels; however, a PaCO2 as low as 15–20 mmHg may lead to excessive vasoconstriction, reducing cerebral blood flow and causing cerebral ischemia. A PaCO2 target closer to 30–35 mmHg is typically recommended, and even this is used cautiously.

B. Routinely suction to prevent accumulation of respiratory secretions. Suctioning can increase ICP due to stimulation of the cough reflex. It should be performed only as needed and in a way that minimizes stimulation, such as preoxygenation and limiting suction duration.

C. Encourage visitation to prevent feelings of isolation. While social support is important, minimizing environmental stimuli (including limiting visitation) is crucial for clients with increased ICP to prevent overstimulation and further increases in ICP.

D. Avoid positioning the client with neck and hip flexion. Maintaining proper alignment of the head and neck is essential to promote venous drainage and reduce intracranial pressure (ICP). Flexion of the neck or hips can impede venous outflow, exacerbate ICP, and compromise cerebral perfusion.

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Correct Answer is C

Explanation

A. Decreased peripheral pulses. Decreased pulses may be related to poor perfusion but are not a hallmark sign of right-sided heart failure.

B. S3 heart murmur. An S3 heart murmur is associated with left-sided heart failure due to fluid overload in the lungs.

C. Distended neck veins: Right-sided heart failure leads to the backup of blood in the systemic circulation, which often causes jugular vein distention (JVD), peripheral edema, and hepatomegaly.

D. Orthopnea. Orthopnea is a symptom of left-sided heart failure, where fluid builds up in the lungs, making it difficult to breathe when lying flat.

A. Morphine B. Lactated Ringers C. Selected Medications D. Dexamethasone E. Mannitol F. Hypertonic saline G. Furosemide

Correct Answer is ["D","E","F","G"]

Explanation

A. Morphine is typically used for pain relief, but it is not used to reduce cerebral edema.

B. Lactated Ringers is a balanced electrolyte solution, but it does not address the need for reducing cerebral edema.

D. Dexamethasone is a corticosteroid used to reduce inflammation and cerebral edema in cases of brain injury.

E. Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing fluid out of the brain and into the bloodstream.

F. Hypertonic saline is used to increase serum osmolality, helping to pull water out of the brain and reduce edema.

G. Furosemide is a loop diuretic that can also help reduce cerebral edema by promoting diuresis.

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A nurse is caring for client with increased intracranial pressure What is an appropriate nursing intervention for the client?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with decompensated heart failure. Which finding would indicate that the client is manifesting right-sided heart failure?

Correct Answer is C

Explanation

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Correct Answer is ["D","E","F","G"]

Explanation

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