An intubated patient has been brought into the emergency room following a head injury due to an acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected
An appropriate nursing intervention would include which of the following?
A) Keep the HOB flat at all times
B) Teach the patient to perform the Valsalva maneuver
C) Administer antipyretics on a PRN basis
D) Perform endotracheal suctioning every hour
Ans: C
Feedback: It is important to manage temperature elevations in a patient with suspected ICP so antipyretics are administered as needed. A hyperthermic state causes increased ICP. The HOB should be elevated 30 degrees. The Valsalva maneuver is to be avoided because it increases ICP. Suctioning should be done on a limited basis due to increasing pressure in the cranium. Stool softeners will be administered.
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