A patient has a head injury and is presenting with signs and symptoms of increased intracranial pressure. Which nursing intervention would be helpful in reducing this pressure?

a. Place the neck in a neutral position to promote venous drainage.
b. Suction hourly to stimulate the cough reflex.
c. Add extra blankets to keep the patient warm.
d. Turn the patient frequently to prevent skin impairment.


A
Place the neck in a neutral position (not flexed or extended) to promote venous drainage.

Nursing

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A variety of factors influence the level of anxiety experienced by the patient faced by a stressful situation. Which would the nurse outline? (Select all that apply.)

a. How others perceive the event b. The number of stressors present at one time c. Degree of change the stressors require d. Present role assumption e. Previous experience with a similar situation

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The nurse is caring for an older patient in a residential care facility. The patient has been extremely irritable the entire day

When modifying the patient's plan of care, which of the following would be an appropriate snack to offer the patient to decrease the irritability? A) Chocolate candy bar B) Handful of raisins C) Granola bar D) Glass of milk

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A patient hurriedly tells the community mental health nurse, "Everything's a disaster! I can't concentrate. My disability check didn't come. My roommate moved out, and I can't afford the rent. My therapist is moving away. I feel like I'm coming apart."

Which nursing diagnosis applies a. Decisional conflict, related to challenges to personal values b. Spiritual distress, related to ethical implications of treatment regimen c. Anxiety, related to changes perceived as threatening to psychological equilibrium d. Impaired environmental interpretation syndrome, related to solving multiple problems affecting security needs ?

Nursing

As you monitor D.H., you observe for prolapse of the umbilical cord. Describe what this is and what can happen to the fetus if this occurs.

What will be an ideal response?

Nursing