The nurse is supervising the care of the patient who is alert but has increased intracranial pressure following head trauma. Which action by the unlicensed assistive personnel (UAP) prompts the nurse to intervene immediately?

Instructs the patient to use the legs to push up in bed. The nurse intervenes if the unlicensed assistive personnel (UAP) instructs the patient to use the legs to push up in bed, because this can induce the Valsalva maneuver and cause a transient but dangerous elevation in intracranial pressure. The UAP would be correct to strictly measure the patient’s urine output, ensure the patient’s sequential compression devices are in place while in bed, and utilize help to log roll the patient to place the fracture pan under the patient.

The nurse is supervising the care of the patient who is alert but...

NCLEX Practice
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Management of Care
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Category: Management of Care
Difficulty: 6

Topics: Delegation, Prioritization and Leadership Neurology

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