The nurse has received a child from the Emergency Department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. The nurse would question which of the following physician's order?
1. Hourly vital signs and neuro checks
2. Passive range-of-motion exercises
3. Elevate head of bed 30 degrees.
4. Oxygen at 2L nasal cannula to keep saturation above 95%
2
Rationale:
1. Hourly vital signs and neuro checks are appropriate to watch for changes in this child's condition.
2. 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.
3. The head is elevated 30 degrees to help to decrease increased intracranial pressure.
4. Oxygen should be ordered to keep the child's O2 saturation above 95%.
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