While caring for a patient with a closed head injury,the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg,heart rate 60 beats/min,respirations 18 breaths/min,and a temperature of 102°F.To reduce the risk of increased intracranial pressure (ICP)in this patient,what is (are)the priority nursing action(s)?
A) Ensure adequate periods of rest between nursing interventions.
B) Insert an oral airway and monitor respiratory rate and depth.
C) Maintain neutral head alignment and avoid extreme hip flexion.
D) Reduce ambient room temperature and administer antipyretics.

Question

Quizplus · Accepted Answer

In this scenario,the patient's temperature is elevated,which increases metabolic demands.Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP).Cooling measures should be implemented.Insertion of an oral airway in an alert patient is contraindicated.While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP,treatment of the fever is of higher priority.

While Caring for a Patient with a Closed Head Injury,the