Which Nursing Intervention for the Patient with Increased Intracranial Pressure would be first priority?
Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway
Maintain a calm, quiet atmosphere and protect patient from stress
Use strict aseptic technique for management of ICP monitoring system
Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage
The Correct Answer is A
Choice A: Frequent monitoring of respiratory status and lung sounds and measures to maintain a patent airway is the first priority, as it can prevent hypoxia, hypercapnia, and increased ICP that can lead to brain herniation and death.
Choice B: Maintain a calm, quiet atmosphere and protect patient from stress is not the first priority, but rather a supportive measure to reduce stimuli and agitation that can increase ICP.
Choice C: Use strict aseptic technique for management of ICP monitoring system is not the first priority, but rather a preventive measure to avoid infection and meningitis that can worsen ICP.
Choice D: Position with head in neutral position and elevation of HOB 0 to 60 degrees to promote venous drainage is not the first priority, but rather a therapeutic measure to facilitate blood flow and reduce ICP.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Head of bed 45 degrees is not enough to prevent aspiration or choking, as the patient may still have difficulty swallowing and clearing their airway.
Choice B: Patient should be on a regular diet to rebuild their swallowing ability is not correct, as the patient may need a modified diet depending on their level of dysphagia or swallowing impairment. A regular diet may pose a risk of aspiration or choking.
Choice C: Have patient sit upright 90 degrees in bed or chair is correct, as this position helps the patient align their head and neck and use gravity to facilitate swallowing and prevent aspiration.
Choice D: All of the above is not correct, as only choice C is appropriate for assisting a stroke patient with feeding.
Correct Answer is D
Explanation
Choice A: Maintenance of clear airway is a goal for a patient with altered level of consciousness, as it can prevent aspiration, hypoxia, and respiratory failure.
Choice B: Maintenance of skin integrity is a goal for a patient with altered level of consciousness, as it can prevent pressure ulcers, infection, and sepsis.
Choice C: Protection from injury is a goal for a patient with altered level of consciousness, as it can prevent falls, fractures, and trauma.
Choice D: All of the above is correct, as all of these goals are relevant for a patient with altered level of consciousness.
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