A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?

Perform active range-of-motion exercises.

Maintain the head at a midline position.

Suction the airway frequently.

Perform neurological checks every 4 hours.

Answer and Explanation

The Correct Answer is B

A. Active range-of-motion exercises are not appropriate for a child with increased intracranial pressure and decreased level of consciousness, as they may increase intracranial pressure.

B. Maintaining the head at a midline position helps promote proper cerebral perfusion and reduces the risk of further increases in intracranial pressure.

C. Frequent suctioning of the airway can stimulate the gag reflex and increase intracranial pressure. Suctioning should only be done as needed to maintain a clear airway.

D. Neurological checks should be performed more frequently than every 4 hours in a child with increased intracranial pressure and decreased level of consciousness, ideally at least every hour or as indicated by the child's condition.

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Correct Answer is A

Explanation

A. The priority action is to remove the client from the source of carbon monoxide poisoning, which in this case is the kerosene space heater. Taking the client outdoors will provide fresh air and reduce exposure to carbon monoxide.

B. Wrapping blankets around the client may further exacerbate the symptoms by trapping the carbon monoxide, worsening the client's condition.

C. While loosening the client's clothing may improve ventilation, it is not as effective as removing the client from the source of exposure.

D. Opening the client's windows may help improve ventilation, but it is not as effective as taking the client outdoors to reduce exposure to carbon monoxide.

A. Explain to the client the consequences of refusal. B. Identify the reason for the client's refusal. C. Document the client's refusal in the medical record. D. Inform the provider of the client's refusal.

Correct Answer is B

Explanation

A. While explaining the consequences of refusal is important, it may not address the underlying reason for the refusal and should come after identifying the reason.

B. Identifying the reason for the client's refusal is the first step in addressing the issue and may help determine the appropriate intervention.

C. Documenting the client's refusal is important but should not be the first action taken without understanding the reason for the refusal.

D. Informing the provider of the client's refusal may be necessary, but it should come after identifying the reason for the refusal and attempting to address it.

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A nurse is planning care for a child who has increased intracranial pressure with a decrease in the level of consciousness. Which of the following interventions should the nurse include inthe plan of care?

Nursing Test Bank

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