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 {"dropdown-group-1":"D"}
Explanation
1. Level of Consciousness:
2. Oxygen Saturation:
Correct Answer is A
Explanation
A. The client has a paralytic ileus is correct. Morphine can cause decreased gastrointestinal motility, which can exacerbate a paralytic ileus.
B. The client is experiencing a myocardial infarction is incorrect. Morphine is commonly used to manage pain and reduce myocardial oxygen demand during a myocardial infarction.
C. The client who has bronchitis pleurisy is incorrect. Morphine can be used for pain control in pleurisy, but it is not contraindicated.
D. The client who is 24 hr postoperative following hip arthroplasty is incorrect. Morphine is used for postoperative pain management.
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