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concept of nursing 1
Increased Intracranial Pressure: Patient Positioning - CE
| Question | Answer |
|---|---|
| Although head elevation generally lowers ICP, what outcome may also occur? | Decreased CPP |
| What is the indicated position for increased ICP in the presence of hypotension? | Flat, supine, head and neck in neutral position |
| In the absence of hypotension, what is the indicated degree of head elevation recommended to reduce ICP significantly without impairing CPP? | 30 degrees |
| When instructing family members about caring for their child after a head injury, which symptom should prompt them to return to the emergency department? | Behavior changes |
| In addition to positioning, which other interventions help prevent increases in ICP? | Maintain a quiet environment and allow time between patient care tasks. |
| Which action puts the patient with a spinal cord injury at greater risk for the development of pressure injuries? | Keeping the patient on a backboard for 8 hours |
| A patient has a MAP of 88 and an ICP of 11. What is the CPP? | 77 mm Hg |
| Which statement by a family member indicates the need for further education concerning a patient with increased ICP? | “I will raise the head to allow television watching if asked.” |
| The nurse checks the patient’s ICP and finds it to be 13 mm Hg. What is the nurse’s next best action? | Continue to monitor the patient. |
| A patient with a spinal cord injury is found with the head flexed into the chest. This position puts the patient most at risk for which complication? | Obstruction of venous outflow |
| When positioning a client to prevent an increase in ICP, the nurse avoids extreme hip flexion. What might contribute to increased ICP as a result of extreme hip flexion? | Increased intraabdominal pressure |
| A client suffered multiple injuries as a result of an all-terrain-vehicle rollover. The client has a severe head injury and has suffered internal trauma resulting in hypotension. What is the best position for this client during resuscitation and | -- |
| evaluation to treat hypotension? | Supine with the head and neck in the neutral position |
| What statement is true regarding proper positioning of a client with increased intracranial pressure and a normal blood pressure? | Keeping the Head midline will promote Increase venous return |
| A client has just returned after neurosurgery for a brain tumor. They are awake and alert. The nurse should instruct the client to report signs and symptoms that may indicate an increase in ICP. What is the symptom that does not need to be reported? | scalp itching |
| The nurse is explaining the management of increased ICP to the client’s family. After describing the process and benefits of positioning, what should the nurse discuss? | Minimizing noxious stimuli such as loud noises |
Created by:
Lightnning54
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