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. Edema is a common early sign of compartment syndrome as increased pressure within the compartment impairs venous outflow, leading to swelling.

B. Shortness of breath is not typically associated with compartment syndrome but may indicate other respiratory or cardiac issues.

C. Petechiae are not typically associated with compartment syndrome but may occur in conditions such as thrombocytopenia or coagulopathy.

D. Change in mental status is not typically associated with compartment syndrome but may indicate other neurological issues.

A. An air leak noted at the insertion site. B. The tubing may be kinked. C. Water needs to be added to the suction-control chamber. D. The suction is set too low.

Correct Answer is B

Explanation

A. An air leak noted at the insertion site would result in continuous bubbling in the water seal chamber, not the absence of tidaling.

B. If the tubing is kinked or obstructed, it can prevent the movement of air in and out of the water seal chamber, leading to the absence of tidaling.

C. If water needs to be added to the suction-control chamber, this would affect the level of suction, not the tidaling in the water seal chamber.

D. If the suction is set too low, it would not necessarily affect the tidaling in the water seal chamber; instead, it would result in inadequate drainage or lack of suction.

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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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