The patient who has severely elevated intracranial pressure following a traumatic brain injury is intubated, sedated, and chemically paralyzed. Which intervention does the nurse include in the plan of care?

Maintain the patient’s head of bed at 30° to ensure accuracy of intracranial pressure monitoring. The plan of care for the patient with severely elevated intracranial pressure (ICP) should include maintaining the patient’s head of bed at 30° to ensure accuracy of ICP monitoring as well as promote drainage of CSF. Placing the patient prone is contraindicated because it interferes with CSF drainage and can worsen ICP. Rectal temperatures and unnecessary deep endotracheal suctioning should be avoided because it can cause the patient to Valsalva and further increase ICP. The patient’s endotracheal tube should be suctioned as necessary (rather than scheduled).

The patient who has severely elevated intracranial pressure follo...

Category: Physiological Adaptation
Difficulty: 6

Topics: Communication & Documentation Neurology Intracranial Regulation Nursing Interventions

Want help? View the answer with rationale.

Additional Physiological Adaptation Questions

The patient with Marfan syndrome presents with difficulty breathing in the supine position and fatigue. Upon palpation, a heave is noted. The nurse anticipates auscultating which heart sound?

Question Type: Multiple Choice - Select One
Difficulty: 10

A patient is found to have hypertension. Which conditions, if present in the patient, indicate the patient has had hypertension for years without being diagnosed? Select all that apply.

Question Type: Multiple Choice - Select All
Difficulty: 4

The 48-year-old patient is brought via ambulance to the emergency room after being found unresponsive by her son. She has a prescription for transdermal fentanyl patches for treatment of cancer pain related to her breast cancer that has metastasized to her pelvis. The patient’s heart rate is 72 bpm, respiratory rate is 4 breaths per minute, and her oxygen saturation is 88%. Her arterial blood gas results are: pH 7.21, PaCO₂ 72 mmHg, PaO₂ 74, HCO₃¯ 23. A thorough assessment reveals 2 fentanyl patches on the patient’s skin. The nurse advocates for which initial action?

Question Type: Multiple Choice - Select One
Difficulty: 8

Show Calculator

Want help? View the answer with rationale.

Rationale

Additional Physiological Adaptation Questions

Nursing Careers

Nursing Degrees

NCLEX