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 C

Explanation

A. Penicillins are generally safe but are not specific for ototoxicity considerations.

B. Aminoglycosides are avoided in cases of tympanic membrane rupture due to their ototoxic potential, which can lead to hearing loss.

C. Fluoroquinolones, particularly those formulated for otic use, are preferred for tympanic membrane ruptures as they are not ototoxic and are safe for middle ear exposure.

D. Cephalosporins are not typically ototoxic but are less commonly used for tympanic membrane ruptures compared to fluoroquinolones.

A. Conjunctivitis B. Retinal Detachment C. Corneal abrasion D. Chalzion

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.

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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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