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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. The client cannot travel by air due to security screening is incorrect; clients with ICDs can travel by air but should inform security personnel about the ICD.

B. The client should hold his cell phone on the side opposite the ICD to avoid interference with the ICD’s functioning.

C. The client can carry his ICD in a small pocket is incorrect; the ICD is implanted and does not need to be carried.

D. The client should avoid the use of small electric devices is not entirely accurate; the client should follow specific guidelines but not avoid all small devices.

A. Nosebleeds B. Temporary loss of smell C. Weight gain D. Mild hearing loss

Correct Answer is A

Explanation

A. Nosebleeds (epistaxis) are a common adverse effect of bevacizumab, as it can cause bleeding due to its anti-angiogenic properties.
B. Temporary loss of smell is not a recognized adverse effect of bevacizumab.
C. Weight gain is not typically associated with bevacizumab treatment.
D. Mild hearing loss is not a common adverse effect of bevacizumab.

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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?

Nursing Test Bank

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