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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Constipation can occur as a side effect of TPN due to decreased bowel motility, but it is not typically considered a serious complication.
B. Respiratory depression can occur as a complication of TPN, particularly if the solution contains high concentrations of dextrose or if the client has underlying respiratory issues.
C. Hypotension can occur as a complication of TPN if the solution is administered too rapidly, leading to fluid overload, but it is less common than respiratory depression.
D. Electrolyte imbalance, particularly hyperglycemia and hypertriglyceridemia, is a common complication of TPN, but it is less likely to cause immediate respiratory depression compared to other complications such as fluid overload.
Correct Answer is C
Explanation
A. Arterial blood gases - Arterial blood gases are not typically assessed before initiating lithium carbonate therapy.
B. Total cholesterol - Total cholesterol levels are not specifically relevant to monitoring lithium therapy.
C. Thyroid hormones - Thyroid function should be assessed before initiating lithium therapy because lithium can affect thyroid function, potentially leading to hypothyroidism.
D. Hemoglobin - While hemoglobin levels may be monitored during lithium therapy, they are not typically assessed prior to initiating treatment.
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