Postoperative care for a patient having a craniotomy to relieve increased intracranial pressure, the nurse should implement which intervention?

Elevate the head of the bed 20 to 30 degrees.

Maintain bright lighting in the room to assess bleeding at the surgical site.

Stimulate the patient every half hour to assess changes in level of consciousness.

Allow the patient to change positions frequently to maintain comfort.

Answer and Explanation

The Correct Answer is A

Choice A reason: Elevating the head of the bed 20 to 30 degrees is an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It helps to reduce the venous pressure and improve the cerebral perfusion.

Choice B reason: Maintaining bright lighting in the room to assess bleeding at the surgical site is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the sensory stimulation and aggravate the intracranial pressure. The nurse should use dim lighting and monitor the dressing and the drainage system for signs of bleeding.

Choice C reason: Stimulating the patient every half hour to assess changes in level of consciousness is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the cerebral metabolic demand and worsen the intracranial pressure. The nurse should assess the level of consciousness using the Glasgow Coma Scale and avoid unnecessary stimulation.

Choice D reason: Allowing the patient to change positions frequently to maintain comfort is not an appropriate intervention for a patient who had a craniotomy to relieve increased intracranial pressure. It can increase the intrathoracic pressure and affect the cerebral blood flow. The nurse should limit the patient's movement and avoid extreme flexion, extension, or rotation of the head and neck.

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Correct Answer is B

Explanation

Choice A reason: Decreasing intracranial pressure with decerebrate posturing is not the correct answer. Decerebrate posturing is a sign of severe brain damage that involves the extension and outward rotation of the arms and legs, and the arching of the back. It is not associated with decreasing intracranial pressure, but rather with increased pressure or brainstem compression.

Choice B reason: Increasing intracranial pressure with decorticate posturing is the correct answer. Decorticate posturing is a sign of severe brain damage that involves the flexion of the arms at the elbows and the extension of the legs. It is associated with increased intracranial pressure or lesions in the cerebral hemispheres.

Choice C reason: Decreasing intracranial pressure with decorticate posturing is not the correct answer. Decorticate posturing is a sign of severe brain damage that involves the flexion of the arms at the elbows and the extension of the legs. It is not associated with decreasing intracranial pressure, but rather with increased pressure or lesions in the cerebral hemispheres.

Choice D reason: Increasing intracranial pressure with decerebrate posturing is not the correct answer. Decerebrate posturing is a sign of severe brain damage that involves the extension and outward rotation of the arms and legs, and the arching of the back. It is associated with increased intracranial pressure or brainstem compression, but it is not the posture described in the question.

A. may be necessary to prevent pulmonary thrombosis. B. is contraindicated because it will cause additional bleeding. C. is inadvisable because it may mask signs and symptoms of neurologic changes in the brain. D. will be started if necessary to enhance cerebral circulation.

Correct Answer is B

Explanation

Choice A reason: This is incorrect. Anticoagulant therapy may be necessary to prevent pulmonary thrombosis in patients with ischemic stroke, which is caused by a blood clot blocking a blood vessel in the brain. However, in patients with hemorrhagic stroke, which is caused by a ruptured blood vessel in the brain, anticoagulant therapy can worsen the bleeding and increase the risk of complications.

Choice B reason: This is correct. Anticoagulant therapy is contraindicated because it will cause additional bleeding in patients with hemorrhagic stroke. Anticoagulants are drugs that prevent blood from clotting or dissolve existing clots. They can increase the size of the hematoma and the pressure on the brain tissue, leading to more damage and disability.

Choice C reason: This is incorrect. Anticoagulant therapy is not inadvisable because it may mask signs and symptoms of neurologic changes in the brain. Anticoagulants do not affect the neurological assessment or the diagnosis of stroke. They can, however, interfere with the treatment and recovery of hemorrhagic stroke.

Choice D reason: This is incorrect. Anticoagulant therapy will not be started if necessary to enhance cerebral circulation in patients with hemorrhagic stroke. Anticoagulants do not improve the blood flow to the brain, but rather prevent or dissolve clots that may obstruct it. In patients with hemorrhagic stroke, the pro

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Postoperative care for a patient having a craniotomy to relieve increased intracranial pressure, the nurse should implement which intervention?

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