A patient with a cerebral injury is experiencing increased intracranial pressure (ICP). Which intervention should the nurse use to help prevent further increasing intracranial pressure?
a. Avoid touching the patient as much as possible.
b. Provide stimulation such as radio and television for 12 hours each day.
c. Provide as much nursing care at one time as possible to allow the patient to rest.
d. Space nursing care at intervals so that necessary care is distributed evenly throughout a shift.
ANS: D
The nurse should space care activities to provide rest between each disturbance. C. Clustering care may raise ICP. B. Stimulation can also raise ICP. A. Avoiding touch is not necessary.
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