Which of the following statements made by a nurse shows the most informed knowledge regarding the positioning of the head of a client being monitored for increasing intracranial pressure (ICP) related to a brain injury that is not vascular in nature
? 1. "The client's intracranial pressure dictates how high I position the head of the bed.".
2. "I am careful to elevate the head of the client's bed to 30 degrees.".
3. "The most controllable factor in managing intracranial pressure (ICP) is head elevation.".
4. "I elevate the client's head when the intracranial pressure is increasing.".
"The client's intracranial pressure dictates how high I position the head of the bed.".
Rationale: The suggestion is that head positioning, both in terms of elevation and rotation, has a definite effect on ICP. However, it is recommended that head position be established on an individual basis, with the help of monitoring devices. A 30-degree elevation, while traditionally accepted, should not be universally accepted for all clients. There are several factors that affect the client's intracranial pressure. Head elevation is used to minimize or prevent IICP and should not be reserved for implementation only after an increase is observed.
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