The nurse is caring for a child with decreased level of consciousness secondary to increased intracranial pressure (IICP) from a head trauma. Which prescription from the healthcare provider should the nurse question?
A) Passive range-of-motion exercises
B) Elevating the head of the bed to 30 °
C) Vital signs and neuro checks every hour
D) Administering oxygen at 2 L nasal cannula to keep saturation above 95%
Answer: A
Range-of-motion exercises would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible. Hourly vital signs and neuro checks are appropriate to watch for changes in this child's condition. The head is elevated 30 ° to help to decrease increased intracranial pressure. Oxygen should be ordered to keep the child's O2 saturation above 95%.
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