The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Encourage the patient to cough to expectorate secretions

Elevate the head of the bed to 30-45 degrees

Stimulate the patient with active range of motion exercises

Perform serial neurologic assessments while hospitalized

Contact the healthcare provider if the ICP is sustained between 30-40mmHg

Answer and Explanation

Correct Answer : B,D,E

A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.

B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.

C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.

D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.

E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications

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Correct Answer is C

Explanation

A. Conjunctivitis (pink eye) is not a typical complication of Bell's Palsy.

B. Retinal detachment is unrelated to the incomplete eye closure seen in Bell’s Palsy.

C. Bell's Palsy often results in incomplete eye closure, which can lead to drying and irritation of the cornea, increasing the risk for corneal abrasions. An eye patch protects the cornea by helping the eye stay moist and protected from injury.

D. A chalazion is a small eyelid bump caused by blocked oil glands, not associated with Bell’s Palsy.

Correct Answer is ["1.3"]

Explanation

To calculate the dosage of clindamycin, first convert the patient's weight from pounds to kilograms, knowing that 1 kg equals 2.2 lbs. The patient weighs 88 lbs, which is equivalent to 40 kg (88 lbs / 2.2 lbs per kg). The prescribed dose is 10 mg/kg/day, so the patient requires 400 mg/day (10 mg/kg * 40 kg). Since the medication is to be administered in two divided doses, each dose will be half of the daily requirement, resulting in 200 mg per dose. The medication is supplied at a concentration of 150 mg/mL, so to find out how many milliliters per dose, divide the dose in milligrams by the concentration: 200 mg / 150 mg/mL, which equals 1.33 mL. Rounded to the nearest tenth, the nurse will administer 1.3 mL per dose.

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The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?

Correct Answer is C

Explanation

A physician prescribes clindamycin 10 mg/kg/day IV in two divided doses for respiratory tract infection. The medication is supplied 150 mg/mL. The patient weighs 88 lbs. How much will the nurse administer per dose? (round to the nearest tenth)

Correct Answer is ["1.3"]

Explanation

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