Ati nur211 mobility exam
Ati nur211 mobility exam ( 29 Questions)
A nurse is attending to a client with a closed-head injury and elevated ICP readings between 16 and 22 mm Hg. What actions should the nurse take to reduce the risk of increasing the client's ICP?
Elevating the client's head on two pillows can help reduce ICP by promoting venous drainage from the brain. However, it is important to ensure that the head is not elevated too high, as this can impede venous return and potentially increase ICP. The recommended elevation is typicallly 30 degrees. While this intervention is beneficial, it is not the most critical action compared to reducing environmental stimuli.
Keeping the client well hydrated is essential for overall health, but excessive hydration can increase ICP by increasing the volume of cerebrospinal fluid and blood within the cranial vault. Fluid management must be carefully monitored to avoid exacerbating ICP. Therefore, while hydration is important, it must be balanced and not excessive.
Decreasing the noise level in the client's room is crucial for minimizing external stimuli that can increase ICP. Noise and other environmental stressors can lead to increased agitation and stress, which in turn can elevate ICP. Creating a calm and quiet environment helps in maintaining a stable ICP and is a non-invasive, easily implementable intervention.
Frequent suctioning of the endotracheal tube can cause transient increases in ICP due to the stimulation and potential for coughing. While suctioning is necessary to maintain airway patency, it should be performed judiciously and only when clinically indicated. Over-suctioning can lead to spikes in ICP and should be avoided.
Choice A Reason:
Elevating the client's head on two pillows can help reduce ICP by promoting venous drainage from the brain. However, it is important to ensure that the head is not elevated too high, as this can impede venous return and potentially increase ICP. The recommended elevation is typicallly 30 degrees. While this intervention is beneficial, it is not the most critical action compared to reducing environmental stimuli.
Choice B Reason:
Keeping the client well hydrated is essential for overall health, but excessive hydration can increase ICP by increasing the volume of cerebrospinal fluid and blood within the cranial vault. Fluid management must be carefully monitored to avoid exacerbating ICP. Therefore, while hydration is important, it must be balanced and not excessive.
Choice C Reason:
Decreasing the noise level in the client's room is crucial for minimizing external stimuli that can increase ICP. Noise and other environmental stressors can lead to increased agitation and stress, which in turn can elevate ICP. Creating a calm and quiet environment helps in maintaining a stable ICP and is a non-invasive, easily implementable intervention.
Choice D Reason:
Frequent suctioning of the endotracheal tube can cause transient increases in ICP due to the stimulation and potential for coughing. While suctioning is necessary to maintain airway patency, it should be performed judiciously and only when clinically indicated. Over-suctioning can lead to spikes in ICP and should be avoided.
