33. The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the child's care plan?
a. Elevate the head of the bed 15 to 30 degrees with the head maintained in midline.
b. Maintain an active, stimulating environment.
c. Perform chest percussion and suctioning every 1 to 2 hours.
d. Perform active range of motion and nontherapeutic touch every 8 hours.
ANS: A
Nursing activities for children with head trauma and increased intracranial pressure (ICP) include elevating the head of the bed 15 to 30 degrees and maintaining the head in a midline position. The nurse should try to maintain a quiet, nonstimulating environment for a child with increased ICP. Chest percussion and suctioning should be performed judiciously because they can elevate ICP. Range of motion should be passive and nontherapeutic touch should be avoided because both of these activities can increase ICP.
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