When caring for an unconscious client with increasing intracranial pressure, the nursing intervention that is contraindicated is :
Elevating the head of the bed 20 degrees
Cleansing the eyes every 4 hours with normal saline
Lubricating the skin with baby oil
Suctioning the oropharynx routinely
The Correct Answer is D
Choice A reason : Elevating the head of the bed to 20 degrees can help reduce intracranial pressure by promoting venous drainage from the brain. It is a recommended practice unless contraindicated by other conditions³.
Choice B reason : Cleansing the eyes with normal saline every 4 hours is a standard care procedure to maintain eye hygiene and prevent infection, especially when the blink reflex may be compromised in an unconscious patient³.
Choice C reason : Lubricating the skin with baby oil is a common practice to prevent dryness and maintain skin integrity. It is not contraindicated unless the patient has specific allergies or skin conditions that require different care³.
Choice D reason : Suctioning the oropharynx routinely is contraindicated as it can stimulate the vagus nerve and potentially increase intracranial pressure. Suctioning should be performed cautiously and only when necessary³.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason : Cleaning dentures in a denture cup is a standard hygiene practice but does not directly address the low WBC count. While maintaining oral hygiene is important, it is not the most critical action related to the client's immunocompromised state⁶.
Choice B reason : Replacing the water in flower vases daily is a good practice to prevent bacterial growth; however, it is recommended to avoid having flowers or plants in the room of an immunocompromised patient due to the risk of exposure to fungi and bacteria⁷.
Choice C reason : Humidifying the room can be beneficial for respiratory comfort, but it must be done with caution in immunocompromised patients. Humidifiers need to be kept clean to prevent the growth of bacteria and fungi, which could be harmful to a patient with a low WBC count⁷.
Choice D reason : Serving cooked fruit with meals is the correct action because cooking fruit can eliminate potential pathogens that the client's compromised immune system may not be able to handle. Raw fruits and vegetables can harbor bacteria and other pathogens, so serving them cooked is a safer option for someone with a low WBC count⁶⁷.
Correct Answer is D
Explanation
Choice A reason : Acting as if the hallucination is real can validate the client's false perceptions and potentially reinforce the hallucination. It is important to maintain a sense of reality and not to enter into the client's hallucinatory experience.
Choice B reason : Instructing the client to argue with the voices is not therapeutic. It can increase the client's agitation and anxiety, and it does not help in distinguishing reality from hallucinations.
Choice C reason : While it is important to understand the client's experience, asking direct questions about the hallucination may lead the client to focus more on the hallucination, which can reinforce its presence. The nurse should focus on reality-based topics.
Choice D reason : This is the correct action. The nurse should gently and firmly reassure the client that the hallucination is not real and is a symptom of their illness. This helps to orient the client to reality and can reduce the distress associated with hallucinations.
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