The nurse is caring for a patient with an acute brain injury. Which interventions should the nurse use to prevent increased intracranial pressure in this patient? (Select all that apply.)
a. Avoid hip flexion.
b. Administer stool softeners.
c. Keep head of bed elevated 30 degrees.
d. Encourage deep breathing and coughing.
e. Administer opioid analgesics for headache.
ANS: A, B, C
Elevation of the head of the bed may help reduce intracranial pressure (ICP). Stool softeners prevent straining, which can increase ICP. Hip flexion may also increase ICP. D. E. Coughing can increase ICP, and opioid analgesics make neurological assessment difficult.
You might also like to view...
In which step of the nursing process does the nurse prioritize the nursing diagnoses and identify interventions to address the patient goals?
a. Assessment b. Planning c. Implementation d. Evaluation
The nurse educator is developing a seminar to help children who have experienced a loss. Which information should the nurse include to help these children adapt?
A) Explain that magical thinking helps with the pain. B) Remind the child that big children don't cry. C) Help create new memories. D) Pretend that the individual has not really gone.
Which of the following should the nurse keep in mind when writing goals and expected outcomes for a client?
a. A goal is a broad statement of desired changes that need not be written in behavioral terms. b. Goals focus on long-term needs, and expected outcomes focus on short-term needs. c. An expected outcome is a specific statement that describes the methods through which the goal will be achieved. d. Long-term goals focus on the etiology component of the nursing diagnosis.
A 70-year-old woman with painful arthritic joints asks the nurse what would be the most beneficial exercise for her based upon her disability. What would be the most appropriate suggestion of the nurse?
a. Train with hand weights. b. Walk on a treadmill. c. Do low-impact aerobics. d. Swim.