An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU
What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?
A) To decrease cerebral arterial pressure
B) To avoid impeding venous outflow
C) To prevent flexion contractures
D) To prevent aspiration of stomach contents
Ans: B
Feedback:
Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this position.
You might also like to view...
Which is a true statement about psychotic behavior in older adults?
a. Usually, hallucinations in older patients are the result of psychological conflicts. b. Illusion, delusion, and hallucination are different terms for the same phenomenon. c. An older adult with psychotic behavior should be assessed for a variety of causes. d. Regardless of the cause, dissimilar hallucinations are treated with similar thera-pies.
Which of the following most accurately describes the relationship between reliability and validity?
A) If a measure is reliable, it will be valid. B) As reliability increases, validity decreases. C) If a measure is not reliable, it cannot be valid. D) There is no direct relationship between the two.
A pregnant patient would like to know a good food source of calcium other than dairy products. Your best answer is
a. Legumes b. Yellow vegetables c. Lean meat d. Whole grains
A nurse has provided routine morning cares to a client, including all the medications and scheduled treatments. The most appropriate action after this is completed is for the nurse to:
1. Move on to the next assignment to increase the nurse's efficiency. 2. Report this to the charge nurse. 3. Document all cares in the progress notes. 4. Get supplies organized for the next client's medications and treatments.