Which of the following nursing interventions would be utilized in controlling intracranial pressure in a severely brain-injured patient?
A) Keep the head of the bed flat
B) Maintain fluid balance with D5W solution
C) Maintain cerebral perfusion pressure at 60 mm Hg or greater
D) Initiate measures to prevent the Valsalva maneuver
Ans: D
Feedback: Measures to avoid the Valsalva maneuver should be implemented in a patient with increased intracranial pressure because it can elevate intracranial pressure and cause serious injury. The head of the bed should be elevated 30 degrees. Fluid balance should be maintained with normal saline solution; D5W promotes cerebral edema. Cerebral perfusion pressure (CPP) should be maintained at greater than 70 mm Hg. See Chart 63-5.
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