The Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected
An appropriate nursing intervention would include what?
A) Keep the HOB flat at all times.
B) Teach the patient to perform the Valsalva maneuver.
C) Administer antipyretics on a prn basis.
D) Perform endotracheal suctioning every hour.
Ans: C
Feedback: It is important to manage temperature elevations in a patient with suspected increased ICP. A hyperthermic state causes increased ICP. The HOB should be elevated 30 degrees. Suctioning should be done a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes increased ICP. Stool softeners will be administered.
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