Which of the following positions should the nurse place a patient in who is experiencing increased intracranial pressure?
1. head of the bed elevated 30 to 45 degrees
2. head of the bed elevated 90 degrees
3. head turned to the side of the surgery
4. supine with the neck in a neutral position
1
Rationale: Elevating the head of the bed 30 to 45 degrees maximizes the venous outflow from the brain. The other positions will all have a negative effect on the patient and may lead to increases in ICP.
You might also like to view...
A mother watches the nurse perform an assessment on her newborn and asks the nurse why she is doing things like "stroking the bottom of his feet." The nurse should respond: "I'm:
1) Checking the blood flow to your baby's feet to make sure it's normal." 2) Testing to see if your baby's neuromuscular system is fully developed." 3) Checking to see if your baby has the reflex responses we anticipate." 4) Testing to see if your baby has normal sensation in his feet."
Which of the following terms refers to the ethical questions that arise out of nursing practice?
1) Nursing ethics 2) Bioethics 3) Ethical dilemma 4) Moral distress
A single mother of four escapes her burning row house but is able to rescue only two of her children. She cries, "I should have gone back in to get them. I should have died, not them. I'm such a terrible mother
God, please forgive me!" The nurse understands that the client is experiencing: A) A crisis resulting from traumatic stress. B) A crisis of anticipated life transition. C) A maturational/developmental crisis. D) A psychiatric emergency.
Which exemplifies a nuclear family?
A) First-degree relatives who live together B) First- and second-degree relatives who live together C) First- and second-degree relatives who live in the same neighborhood D) Individuals who are not blood relatives but share a common locale of origin or culture