The nurse is caring for a patient with a cerebral injury with increased intracranial pressure (ICP). Which intervention can help prevent further increasing intracranial pressure?
a. Provide as much nursing care at one time as possible to allow the patient to rest.
b. Space nursing care at intervals so that necessary care is distributed evenly throughout a shift.
c. Provide stimulation such as radio and television for 12 hours each day.
d. Avoid touching the patient as much as possible.
ANS: B
The nurse should space care activities to provide rest between each disturbance, because clustering care may raise ICP. Stimulation can also raise ICP. Avoiding touch is not necessary.
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