The nurse has received a child from the emergency department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. Which physician's order would the nurse question?
1. Passive range-of-motion exercises
2. Oxygen at 2L nasal cannula to keep saturation above 95%
3. Hourly vital signs and neuro checks
4. Elevate head of bed 30 degrees
1
Rationale 1: Range-of-motion exercises would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible.
Rationale 2: Oxygen should be ordered to keep the child's O2 saturation above 95%.
Rationale 3: Hourly vital signs and neuro checks are appropriate to watch for changes in this child's condition.
Rationale 4: The head is elevated 30 degrees to help decrease increased intracranial pressure.
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