Understanding The Essentials Of Critical Care Nursing 2nd Edition By Kathleen – Test Bank

19) The nurse is planning care for a patient with increased intracranial pressure. Which of the following
interventions would be appropriate for this patient?
1. Cluster care activities.
2. Maintain head of bed at a 15-degree angle with knee elevation.
3. Assess for daily bowel movement and provide intervention as appropriate.
4. Encourage family and physician to discuss patientʹs care and prognosis in the patientʹs room.
Answer: 3
Explanation:

1. When a patient engages in a Valsalva maneuver such as when he strains when having a bowel
movement or pushes himself up in bed, his ICP usually rises. Many neurosurgeons will
provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is
necessary to ensure that the patient has a daily soft bowel movement without straining. The
patientʹs ICP may rise when nursing activities are delivered in a traditional ʺclusterʺ fashion,
with one activity following another. The ICP may rise with the first activity and continue to
rise with each additional activity. The patientʹs ICP should be permitted to return to baseline
before continuing with other activities. The head of the patientʹs bed should be elevated at 30
degrees to allow for adequate cerebral perfusion while promoting venous return from the
head. The body and neck should be in alignment without knee elevation. Keeping external
stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes
discussion around the patient by both the family and the health care team. Some studies have
demonstrated a rise in a patientʹs ICP when discussions about the patient were conducted
around him that did not include him.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
2. When a patient engages in a Valsalva maneuver such as when he strains when having a bowel
movement or pushes himself up in bed, his ICP usually rises. Many neurosurgeons will
provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is
necessary to ensure that the patient has a daily soft bowel movement without straining. The
patientʹs ICP may rise when nursing activities are delivered in a traditional ʺclusterʺ fashion,
with one activity following another. The ICP may rise with the first activity and continue to
rise with each additional activity. The patientʹs ICP should be permitted to return to baseline
before continuing with other activities. The head of the patientʹs bed should be elevated at 30
degrees to allow for adequate cerebral perfusion while promoting venous return from the
head. The body and neck should be in alignment without knee elevation. Keeping external
stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes
discussion around the patient by both the family and the health care team. Some studies have
demonstrated a rise in a patientʹs ICP when discussions about the patient were conducted
around him that did not include him.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential

Understanding the Ess. of Critical Care Nursing (Perrin) — CVC 12/3/08 — Page 251

3. When a patient engages in a Valsalva maneuver such as when he strains when having a bowel
movement or pushes himself up in bed, his ICP usually rises. Many neurosurgeons will
provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is
necessary to ensure that the patient has a daily soft bowel movement without straining. The
patientʹs ICP may rise when nursing activities are delivered in a traditional ʺclusterʺ fashion,
with one activity following another. The ICP may rise with the first activity and continue to
rise with each additional activity. The patientʹs ICP should be permitted to return to baseline
before continuing with other activities. The head of the patientʹs bed should be elevated at 30
degrees to allow for adequate cerebral perfusion while promoting venous return from the
head. The body and neck should be in alignment without knee elevation. Keeping external
stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes
discussion around the patient by both the family and the health care team. Some studies have
demonstrated a rise in a patientʹs ICP when discussions about the patient were conducted
around him that did not include him.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
4. When a patient engages in a Valsalva maneuver such as when he strains when having a bowel
movement or pushes himself up in bed, his ICP usually rises. Many neurosurgeons will
provide orders for a variety of stool softeners or laxatives. The nurse then uses whichever is
necessary to ensure that the patient has a daily soft bowel movement without straining. The
patientʹs ICP may rise when nursing activities are delivered in a traditional ʺclusterʺ fashion,
with one activity following another. The ICP may rise with the first activity and continue to
rise with each additional activity. The patientʹs ICP should be permitted to return to baseline
before continuing with other activities. The head of the patientʹs bed should be elevated at 30
degrees to allow for adequate cerebral perfusion while promoting venous return from the
head. The body and neck should be in alignment without knee elevation. Keeping external
stimulation to a minimum has been demonstrated to limit the rise in ICP. This includes
discussion around the patient by both the family and the health care team. Some studies have
demonstrated a rise in a patientʹs ICP when discussions about the patient were conducted
around him that did not include him.
Nursing Process: Implementation
Cognitive Level: Application
Category of Need: Physiological Integrity–Reduction of Risk Potential
Learning Outcome: 9-7: Discuss the collaborative management of the patient with a severe traumatic brain injury