The nurse is providing care for a pediatric client in the emergency department (ED) with a diagnosis of decreased level of consciousness (LOC) secondary to increased intracranial pressure (ICP). Which healthcare provider order should the nurse question?
1. Passive range-of-motion exercises to promote hip flexion
2. Oxygen at 2 L nasal cannula to keep saturation above 95%
3. Hourly vital signs and neurologic checks
4. Elevate head of bed 30 degrees
1
Explanation:
1. Range-of-motion exercises, especially hip flexion, would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible.
2. Oxygen should be ordered to keep the child's O2 saturation above 95%.
3. Hourly vital signs and neurologic checks are appropriate to watch for changes in this child's condition.
4. The head is elevated 30 degrees to help decrease increased intracranial pressure.
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