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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Place the client's valuables in the facility's safe - While securing the client's valuables is important, it is not the priority upon admission.
B. Observe the client's level of mobility - This is the priority as it allows the nurse to assess the client's immediate physical condition and risk of falls or other mobility-related issues.
C. Administer prescribed medications - Medication administration can wait until the client's initial assessment, including mobility, has been completed.
D. Electronically enter the prescriptions from the provider - Entering prescriptions can be done after the initial assessment and immediate needs of the client have been addressed.
Correct Answer is ["A","B","D","E"]
Explanation
A. Echolalia, or repeating the words of others, can be a manifestation of schizophrenia.
B. Word salad, or a jumble of incoherent words and phrases, can occur in schizophrenia.
C. Expressing interest in ADLs is not typically associated with schizophrenia and may indicate a different mental health state.
D. A blunt affect, or reduced emotional expression, is a common symptom of schizophrenia.
E. Delusions, or fixed false beliefs, are a hallmark symptom of schizophrenia.
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