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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Timolol is a beta-blocker that can be absorbed systemically, leading to side effects such as bradycardia and hypotension, which require monitoring.
B. Tachycardia and dry cough are not common side effects of timolol; dry cough is more associated with ACE inhibitors.
C. Scleral injection and tearing are not common side effects and are not expected with timolol use.
D. Changes in eye pigmentation are more commonly seen with prostaglandin analogs, not with beta-blockers like timolol.
Correct Answer is ["B","D","E"]
Explanation
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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