A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?
Flex the client's hip.
Hyperextend the client's neck.
Provide warming measures for the client.
Adjust the client's head of bed.
The Correct Answer is D
A. Flex the client’s hip is incorrect. Flexing the hip can increase intra-abdominal pressure and potentially increase intracranial pressure.
B. Hyperextend the client’s neck is incorrect. Hyperextension of the neck can interfere with venous return from the brain and increase ICP.
C. Provide warming measures for the client is incorrect. Warming measures are not indicated for a low CPP; maintaining normothermia is important, but warming is not the priority action.
D. Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Take this medication with orange juice is incorrect; alendronate should be taken with plain water to avoid food or drink interactions.
B. Take this medication with food is incorrect; alendronate should be taken on an empty stomach to enhance absorption.
C. Sit upright or stand for at least 30 minutes after taking this medication helps prevent esophageal irritation and ensure the medication reaches the stomach.
D. Chew or suck on the tablet is incorrect; the effervescent tablet should be dissolved in water as directed.
Correct Answer is ["B","D","E"]
Explanation
A. Hypotension is not typically associated with ESRD; hypertension is more common due to fluid retention and alterations in renin-angiotensin system.
B. Bone pain is common in ESRD due to disturbances in calcium and phosphate metabolism, leading to renal osteodystrophy.
C. Bradypnea is not an expected finding; however, patients may exhibit Kussmaul respirations if they have metabolic acidosis.
D. Slurred speech is a typical finding in ESRD.
E. Pruritus is a common symptom in ESRD due to the buildup of uremic toxins and alterations in calcium and phosphate metabolism.
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