A patient is admitted to the ED (emergency department) with an intracranial problem. Upon arrival the RN (registered nurse) immediately ensures that the head of the bed is elevated at 35 degrees. Identify the pathophysiological rational for this intervention?
Elevating the head of the bed promotes venous return and helps increase the ICP.
Elevation of the head of the bed aids in maintaining cerebral perfusion.
Elevation of the head of the bed will increase intracranial pressure (ICP).
The nurse should keep the head of the bed flat to ensure adequate arterial circulation.
The Correct Answer is B
A. Elevating the head of the bed promotes venous return and helps increase the ICP: This is incorrect. Elevation of the head of the bed helps to decrease intracranial pressure (ICP) by promoting venous drainage rather than increasing it.
B. Elevation of the head of the bed aids in maintaining cerebral perfusion: Elevating the head of the bed helps to decrease ICP, which in turn aids in maintaining adequate cerebral perfusion pressure.
C. Elevation of the head of the bed will increase intracranial pressure (ICP): This is incorrect. Elevation of the head of the bed is intended to reduce ICP, not increase it.
D. The nurse should keep the head of the bed flat to ensure adequate arterial circulation: This is incorrect. Keeping the head of the bed flat can increase ICP, which is counterproductive in managing intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. His body does not produce any insulin so he must receive insulin injections: Type I diabetes is characterized by the destruction of pancreatic beta cells, resulting in little to no insulin production. Therefore, insulin must be administered via injection to replace the insulin the body cannot produce.
B. The pills are not as effective as the insulin injections: While this might be partially true for Type I diabetes, it is not the complete answer. Oral medications are generally not effective in Type I diabetes because they stimulate the pancreas to produce insulin, which is not possible in these patients.
C. He will only be on insulin injections for a short while, then he can take a pill: This is incorrect. Type I diabetes requires lifelong insulin therapy.
D. He can stop the insulin injections once his body begins to make insulin again: This is incorrect as Type I diabetes is a permanent condition where the body cannot produce insulin.
Correct Answer is A
Explanation
A. Adherence to a low-fat diet: The patient likely experienced a transient ischemic attack (TIA), which is a warning sign for future strokes. A low-fat diet is recommended to help manage cholesterol and reduce the risk of atherosclerosis and stroke.
B. The administration of clot-busting drugs: Clot-busting drugs (thrombolytics) are used in the acute management of a stroke, but this patient’s symptoms resolved spontaneously, and the focus is on prevention.
C. Reporting any signs of heat or cold intolerance: This is unrelated to the prevention of stroke or management after a TIA.
D. Avoiding red wine and chocolate: While moderation in alcohol and certain foods is generally advised for overall health, this specific recommendation does not address the primary concern of preventing future cerebrovascular events.
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