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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Metoprolol, a beta-blocker, decreases the heart rate and reduces myocardial oxygen demand by lowering the workload on the heart, which is beneficial for managing unstable angina.
B. While metoprolol has some vasodilatory effects, its primary action is to reduce heart workload, not to dilate coronary arteries.
C. Although beta-blockers can reduce the risk of arrhythmias, the main purpose in angina management is to decrease cardiac workload.
D. Metoprolol does not make the heart beat more forcefully; instead, it decreases the force of contraction to reduce myocardial oxygen consumption.
Correct Answer is D
Explanation
A. Posterior cord injury usually affects proprioception rather than causing a distinctive pattern of motor and sensory loss.
B. Anterior cord injury generally impacts motor function and temperature and pain sensation bilaterally, not in a hemisection pattern.
C. Central cord injury primarily affects motor function in the upper extremities and is not characterized by ipsilateral motor and contralateral sensory loss.
D. Brown-Sequard syndrome typically presents with motor function loss on the same (ipsilateral) side of the injury and loss of pain and temperature sensation on the opposite (contralateral) side, making this the most likely diagnosis.
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