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 : Tarry stools, also known as melena, can be a sign of gastrointestinal bleeding, which may occur in cirrhosis due to the development of esophageal varices. However, it is not a direct symptom of cirrhosis itself but rather a complication that can arise from the condition¹.
Choice B reason : Blood in the urine is not a typical finding associated with cirrhosis. While cirrhosis can lead to problems with kidney function, hematuria is not a direct symptom of liver disease and may indicate other urological conditions¹.
Choice C reason : Moist skin is not commonly associated with cirrhosis. Patients with cirrhosis often experience skin changes, but these typically include jaundice, bruising, and spider angiomas, not increased moisture of the skin¹.
Choice D reason : Spider angiomas are a common finding in cirrhosis. They are small, spider-like capillaries visible under the skin and are caused by the increased estrogen levels that occur due to the liver's inability to metabolize hormones properly. They are most often found on the face, neck, upper chest, and arms¹².
Correct Answer is D
Explanation
Choice A reason : Ecchymosis of the extremities is not a typical finding associated with common bile duct obstruction. It refers to bruising, which can have many causes unrelated to bile duct issues⁴.
Choice B reason : Straw-colored urine is usually a sign of well-hydrated and healthy individuals. In the case of common bile duct obstruction, the urine may actually become darker due to increased bilirubin levels⁴.
Choice C reason : Tenderness in the left upper abdomen is more commonly associated with issues related to the stomach, spleen, or pancreas, not the common bile duct⁴.
Choice D reason : Clay stools are a classic symptom of common bile duct obstruction. When bile flow is blocked, stools can lose their normal brown color and appear pale or clay-colored due to the absence of bilirubin⁴.
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