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 C

No explanation

A. Position the examination light toward the client's face. B. Stand on the right side of the client when examining the left eye. C. Dim the lights in the room prior to the examination. D. Place the ophthalmoscope directly against the client's forehead.

Correct Answer is B

Explanation

A. The examination light of the ophthalmoscope should be directed toward the client's eye, not the client's face.

B. When examining the left eye, the nurse should stand on the right side of the client to facilitate proper alignment of the ophthalmoscope with the client's eye.

C. Dimming the lights in the room may improve visualization of the client's internal eye

structures, but it is not typically necessary for ophthalmoscopic examination and may hinder the nurse's ability to assess the client effectively.

D. Placing the ophthalmoscope directly against the client's forehead would not facilitate proper examination of the internal eye structures and may cause discomfort to the client.

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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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