The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

Suction the patient to minimize secretions

Continue with the assessment and document the finding

Notify the physician and raise HOB to 35-45 degrees

Lower the head of the bed and pad the side rails

Answer and Explanation

The Correct Answer is C

A. Suctioning can increase ICP due to the Valsalva response and should only be done if absolutely necessary.

B. Documenting without intervention could lead to worsening of the patient's condition.

C. Notifying the physician and raising the head of the bed helps to reduce ICP by promoting venous drainage. An ICP of 30 mmHg is critically high, requiring immediate intervention to prevent further damage.

D. Lowering the head of the bed can increase ICP further; head elevation is recommended to improve cerebral drainage.

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Correct Answer is A

Explanation

A. Standard precautions should be used for all patients, including those with AIDS, as they are designed to prevent the transmission of infections regardless of the patient's diagnosis. This includes the use of gloves, hand hygiene, and proper disposal of sharps.

B. Droplet precautions are specific to diseases that are spread through respiratory droplets, which is not the primary concern in AIDS management.

C. Contact precautions are used for infections that can be transmitted through direct contact with the patient or contaminated surfaces, but are not routinely required for AIDS patients unless they have co-infections.

D. Behavioral precautions are not a recognized category for infection control in clinical settings.

A. Ability to process multiple pieces of information at the same time B. Playing chess with fellow patients within one week of admission C. Difficulty planning and organizing thoughts and behaviors D. Being increasingly non-compliant with therapeutic care plans

Correct Answer is C

Explanation

A. Chronic head injury patients often struggle with processing multiple pieces of information simultaneously due to cognitive limitations.

B. Activities requiring complex strategy, like chess, are typically challenging shortly after admission and not a realistic expectation.

C. Difficulty with planning and organizing thoughts and behaviors is a common cognitive deficit in patients with chronic head injury due to impaired executive function, often resulting from damage to the frontal lobe.

D. While non-compliance can occur, it is less predictable and may not be directly linked to chronic head injury itself.

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The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assigned a patient diagnosed with acquired immunodeficiency syndrome (AIDS). Which type of precaution should be used when providing direct care?

Correct Answer is A

Explanation

Which behavior(s) by the patient diagnosed with a chronic head injury would the nurse expect to find?

Correct Answer is C

Explanation

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