a nurse is caring for a client who has increased intracranial pressure icp which of the following interventions should the nurse implement

ATI RN

ATI Capstone Adult Medical Surgical Assessment 1

1. A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?

A. Place several pillows behind the client's head
B. Place the client in a Sim's position
C. Keep the client's neck in a midline position
D. Maintain flexion of the client's hips at a 90Â° angle

Correct answer: C

Rationale: Keeping the client's neck in a midline position is crucial for managing increased intracranial pressure. This position helps optimize blood flow and minimizes the risk of further increasing ICP. Placing several pillows behind the client's head (Choice A) may inadvertently elevate the head, potentially worsening ICP. Placing the client in a Sim's position (Choice B) or maintaining flexion of the client's hips at a 90Â° angle (Choice D) are not directly related to managing increased ICP.

2. What dietary changes should be implemented for a patient with GERD?

A. Avoid mint and spicy foods
B. Eat large meals before bedtime
C. Consume liquids with meals
D. Drink milk as a snack

Correct answer: A

Rationale: The correct answer is A: Avoid mint and spicy foods. Patients with GERD should avoid mint and spicy foods because they can increase gastric acid production, exacerbating symptoms. Choice B is incorrect because eating large meals before bedtime can worsen GERD symptoms due to lying down with a full stomach. Choice C is incorrect as consuming liquids with meals can lead to increased pressure on the lower esophageal sphincter, promoting acid reflux. Choice D is also incorrect as drinking milk as a snack is not recommended for GERD patients, as it may temporarily soothe symptoms but can ultimately stimulate acid production.

3. What is the priority action when the nurse administers insulin for a misread blood glucose reading?

A. Monitor for signs of hypoglycemia
B. Monitor for hyperglycemia
C. Administer glucose IV
D. Document the incident

Correct answer: A

Rationale: The priority action when the nurse administers insulin for a misread blood glucose reading is to monitor for signs of hypoglycemia. Insulin administration based on a misread blood glucose could lead to hypoglycemia due to an unnecessary dose. Monitoring for signs of hypoglycemia is crucial for prompt intervention if blood glucose levels drop dangerously low. Option B, monitoring for hyperglycemia, is incorrect in this situation as the concern is over-treatment with insulin causing hypoglycemia. Option C, administering glucose IV, is only necessary if hypoglycemia occurs. Option D, documenting the incident, is important for reporting and learning purposes but is not the immediate priority when the focus is on patient safety and preventing complications.

4. What are the expected findings in a patient with a thrombotic stroke?

A. Gradual loss of function on one side of the body
B. Sudden loss of consciousness
C. Severe headache and vomiting
D. Loss of sensation in the affected limb

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. In a thrombotic stroke, a blood clot forms in an artery supplying blood to the brain, leading to reduced blood flow to a specific area of the brain. This results in a gradual onset of neurological deficits, such as weakness, numbness, or paralysis on one side of the body. Choices B, C, and D are incorrect because sudden loss of consciousness, severe headache and vomiting, and loss of sensation in the affected limb are more commonly associated with other types of strokes or medical conditions, not specifically thrombotic strokes. Thrombotic strokes typically present with gradual symptoms due to the gradual blockage of blood flow, leading to a progressive neurological deficit.

5. What should the nurse do if a patient experiences abdominal cramping during enema administration?

A. Lower the height of the solution container
B. Increase the flow of the enema solution
C. Stop the procedure and remove the tubing
D. Continue the enema at a slower rate

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the solution container. This adjustment can help alleviate the cramping by reducing the speed and pressure of the solution entering the colon. Increasing the flow of the enema solution (Choice B) can exacerbate the cramping. Stopping the procedure and removing the tubing (Choice C) may be necessary in extreme cases but is not the initial step. Continuing the enema at a slower rate (Choice D) may not effectively address the cramping, making it less optimal than lowering the height of the solution container.