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. Initiating IV access is a priority to establish a route for medication administration and fluid resuscitation, which are crucial in the management of acute pancreatitis.
B. Administering pain medication is important, but establishing IV access should be prioritized to ensure timely delivery of medications and fluids.
C. Sending the client to radiology for a CT scan may be necessary but should not take precedence over establishing IV access for immediate intervention.
D. Inserting an NG tube may be indicated later in the client's care but is not the first priority compared to establishing IV access.

A. Speak directly into one of the client's ears. B. Rephrase sentences the client does not understand. C. Drop voice volume at the end of sentences. D. Exaggerate lip movements.

Correct Answer is B

Explanation

A. Speaking directly into one of the client's ears may not effectively improve communication for someone with a hearing impairment, especially if the impairment is bilateral.

B. Rephrasing sentences the client does not understand can help improve comprehension by providing information in a different way.

C. Dropping voice volume at the end of sentences may make it difficult for the client to hear the end of the sentence, especially if they have a hearing impairment.

D. Exaggerating lip movements may not be helpful and can actually make lip-reading more difficult for some individuals.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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