What other interventions would be appropriate to implement while caring for K.B. that
would assist in reducing intracranial pressure (ICP)?
What will be an ideal response?
• Position him to avoid flexion of the hips, the waist, and the neck and rotation of the head,
especially to the right.
• Instruct him to avoid isometric or resistive exercises. Provide passive range-of-motion exercises.
Instruct him not to move himself in bed.
• Instruct him to avoid coughing and sneezing or, if unavoidable, to do so with an open mouth. Use
as-needed medications for cough and nausea or vomiting as prescribed.
• Implement measures to help avoid the Valsalva maneuver.
• Titrate oxygen as prescribed to improve cerebral perfusion.
• Use a hypothermia blanket to control body temperature (increased body temperature increases
brain damage).
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The client is describing her trip to town. She tells the nurse, "I cold town yellow water girl outside below ground." This speech disturbance is called:
a. Neologism b. Word salad c. Flight of ideas d. Verbigeration
Which of the following must be involved for an act to be considered a terrorist act?
a. A commitment to a political or religious belief b. An attempt to force compliance with a particular set of religious or political beliefs and behaviors c. Fear, intimidation, and violence d. Violence resulting in plural deaths
A client being treated for cancer has a tumor designation of Stage IV, T4, N3, M1. What does this staging indicate to the nurse?
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The school nurse is presenting a class on smoking cessation at the local high school. A participant in the class asks the nurse about the risk of lung cancer in those who smoke
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