Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
A) Keep the head of the bed (HOB) flat at all times.
B) Teach the patient to perform the Valsalva maneuver.
C) Administer benzodiazepines on a PRN basis.
D) Perform endotracheal suctioning every hour.
Ans: C
Feedback:
If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or 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.
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