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. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.

B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.

C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.

D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.

A. Initiate a 1:1 observation status B. Point out the behavior as unacceptable C. Ask the patient why they are behaving that way D. Have the patient return to his room

Correct Answer is B

Explanation

A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.

B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.

C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.

D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.

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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?

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