When providing education to a student nurse about ways to avoid increased intracranial pressure, which of the following will the nurse include in the instructions?(Select All that Apply.)
Consult with dietary
Keep the client's head at 25 degrees or lower
Dim the lights
A stool softener will be ordered
Keep a yankaur suction set up at bedside
Correct Answer : A,B,C,D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A GCS score of 3 for eye opening indicates that the client opens their eyes in response to speech. This accurately reflects the client's level of responsiveness.
B. A GCS score of 5 for motor response indicates that the client localizes pain or can follow simple motor commands. However, this does not fully encapsulate the most appropriate conclusion, given the specific GCS score for eye opening.
C. A total GCS score of 13 (3 for eye opening, 5 for verbal response, and 5 for motor response) suggests mild impairment, not unconsciousness. Unconsciousness is typically indicated by a GCS score of 8 or below.
D. A GCS score of 5 for verbal response indicates the client is oriented and can respond verbally, so they are capable of making vocal sounds.
Correct Answer is B
Explanation
A. "Wear an eye patch on the right eye at all times."
An eye patch may be recommended alternating between eyes for short periods to relieve diplopia, but wearing it continuously on one eye can lead to eye strain and decreased depth perception.
B. "Implement a schedule to include periods of rest."
Fatigue is a common and debilitating symptom in clients with MS. Scheduling regular rest periods helps prevent overexertion, which can worsen symptoms and increase the risk of relapse.
C. "Engage in a vigorous exercise program."
Vigorous exercise may exacerbate MS symptoms, particularly fatigue and heat sensitivity. Instead, a moderate, low-impact exercise program (e.g., swimming, yoga) is more appropriate.
D. "Plan to relax in a hot tub spa each day."
Heat can worsen MS symptoms (a phenomenon known as Uhthoff’s sign). Hot environments, such as hot tubs or spas, should be avoided to prevent symptom exacerbation.
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