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.
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Related Questions
Correct Answer is ["A","E"]
Explanation
A. Place a pillow under the client's head.
Rationale: This action helps to prevent head injury during a seizure by cushioning the head.
B. Place the client into a supine position.
Rationale: This is incorrect because it can increase the risk of aspiration. The client should be placed in a side-lying position to allow the mouth to drain and prevent aspiration.
C. Apply restraints.
Rationale: This is incorrect as restraints can cause injury to the client during a seizure. The nurse should instead ensure the environment is safe and free from objects that could harm the client.
D. Insert a bite stick into the client's mouth.
Rationale: This is incorrect because inserting any object into the mouth during a seizure can cause dental injury or aspiration. The jaw should not be forced open.
E. Loosen restrictive clothing.
Rationale: This action helps to prevent injury and allows for easier breathing during a seizure. It also prevents any constriction that could occur due to muscle contractions.
Correct Answer is B
Explanation
A. First-degree AV block shows a prolonged PR interval but not necessarily an irregular heart rate or a significant pulse deficit.
B. Atrial fibrillation is characterized by a rapid and irregular heart rate with a significant pulse deficit, which aligns with the client's symptoms.
C. Sinus tachycardia presents with a rapid but regular heart rate, not irregular palpitations.
D. Sinus bradycardia shows a slow heart rate and is not associated with an irregular heart rate or significant pulse deficit.
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