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 D

Explanation

A. Herpes simplex virus 2: Herpes simplex virus infections are not typically reportable to the

Centers for Disease Control and Prevention (CDC). These infections are commonly managed at the local level.

B. Candida albicans: Candida albicans infections are not typically reportable to the CDC. Candida species are common pathogens and are usually managed at the local level.

C. Staphylococcus aureus: Staphylococcus aureus infections, including methicillin-resistant

Staphylococcus aureus (MRSA), are not typically reportable to the CDC unless part of a larger outbreak or public health concern.

D. Lyme disease: Lyme disease is a reportable infection that requires notification to public health authorities, including the Centers for Disease Control and Prevention (CDC). Lyme disease is a vector-borne illness transmitted through the bite of infected ticks.

A. The client tucks his chin while swallowing food. B. The client sits upright in bed during meals. C. The client pockets food on one side of his mouth. D. The client has a cough reflex.

Correct Answer is C

Explanation

A: Tucking the chin while swallowing can actually help prevent aspiration in clients with dysphagia, as it narrows the tracheal opening and helps direct food away from the airway.

B: Sitting upright during meals is a recommended practice to reduce the risk of aspiration. It allows gravity to assist with the movement of food, reducing the likelihood of it entering the airway.

C: Pocketing food on one side of the mouth can be a sign of reduced sensation or motor control on that side, often a result of a stroke. This can lead to unnoticed accumulation of food which may then be aspirated.

D: A cough reflex is a protective mechanism against aspiration. If food enters the airway, the cough reflex should trigger, helping to expel the food from the airway and prevent aspiration.

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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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Explanation

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