Which of these measures is appropriate for a patient diagnosed with increased intracranial pressure?

Suction every 2 hours.

Provide rest periods between nursing procedures.

Encourage active range of motion.

Assign the patient to a semiprivate room near the nurse's station.

Answer and Explanation

The Correct Answer is B

Choice A reason: Suctioning every 2 hours is not appropriate for a patient with increased intracranial pressure (ICP). Suctioning can increase ICP due to the stress and stimulation it causes. It should only be performed when absolutely necessary and with proper precautions to minimize ICP spikes.

Choice B reason: Providing rest periods between nursing procedures is the correct measure. This helps minimize stimulation and stress, which can increase ICP. Rest periods allow the patient to stabilize and reduce the risk of further increasing the pressure within the skull.

Choice C reason: Encouraging active range of motion exercises is not suitable for a patient with increased ICP. Physical activity can exacerbate the condition by increasing intracranial pressure. The focus should be on minimizing activity and stress to prevent further elevation of ICP.

Choice D reason: Assigning the patient to a semiprivate room near the nurse's station is not the best approach. Patients with increased ICP require a quiet and calm environment to help manage their condition. A semiprivate room near the nurse's station may expose the patient to more noise and activity, which could increase ICP.

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Correct Answer is D

Explanation

Choice A reason: Hypotension and a decreased level of consciousness can occur in spinal shock due to the disruption of the sympathetic nervous system, but these are not the hallmark features. They are more secondary effects rather than the primary presentation.

Choice B reason: Stridor, garbled speech, or inability to clear the airway are not typical findings in spinal shock. These symptoms are more indicative of airway obstruction or respiratory distress, which are not directly related to spinal shock.

Choice C reason: Bradycardia and decreased urinary output can occur in spinal shock due to the loss of sympathetic tone, leading to unopposed parasympathetic activity. While these are relevant symptoms, they do not encompass the full scope of spinal shock.

Choice D reason: The primary findings in spinal shock are the temporary loss of motor, sensory, reflex, and autonomic function below the level of the spinal injury. This includes flaccid paralysis, loss of reflexes, and autonomic dysfunction, such as hypotension and bradycardia. These symptoms are the most defining characteristics of spinal shock.

A. "When the antibiotic therapy is complete." B. "As soon as his albumin levels return to normal." C. "Once we complete the fluid resuscitation process." D. "When all of his burn wounds have closed."

Correct Answer is D

Explanation

Choice A reason: Completion of antibiotic therapy does not necessarily correlate with a decrease in the risk of infection in burn patients. While antibiotics can help manage existing infections, the risk for new infections remains until the burn wounds are fully healed. Open burn wounds provide a portal of entry for pathogens, and the presence of necrotic tissue can further increase infection risk.

Choice B reason: Returning albumin levels to normal can improve the overall nutritional status and healing process of a burn patient, but it does not directly reduce the risk of infection. Albumin levels are more indicative of the patient's nutritional status and fluid balance. The primary concern for infection risk remains the open burn wounds, which serve as a direct route for pathogens.

Choice C reason: Completion of the fluid resuscitation process is crucial for stabilizing a burn patient's hemodynamic status and ensuring adequate perfusion to tissues. However, fluid resuscitation does not directly impact the risk of infection. The risk of infection is predominantly related to the presence and extent of open burn wounds.

Choice D reason: The correct response is that the risk for infection significantly decreases when all of the burn wounds have closed. Closed wounds provide a barrier against pathogens and reduce the risk of infection. Wound closure can be achieved through natural healing or surgical interventions such as skin grafting. Until the wounds are fully closed, the patient remains at a high risk for infection.

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Which of these measures is appropriate for a patient diagnosed with increased intracranial pressure?

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Naxlex Comprehensive Predictor Exams

What findings would the nurse expect when caring for a client who is experiencing spinal shock?

Correct Answer is D

Explanation

A nurse cares for a patient who has burn injuries. The patient's wife asks, "When will his high risk for infection decrease?" How would the nurse respond?

Correct Answer is D

Explanation

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