Kevin, 23 years old, was admitted for closed head injury following a motor vehicle accident. Which of the following interventions should the nurse plan that would minimize increased intracranial pressure?

Question

Quizplus · Accepted Answer

Positioning the client to maintain the head and neck alignment will facilitate cerebral spinal fluid drainage and prevent increased intracranial pressure due to impediment of spinal fluid drainage.
The head of bed should be elevated greater than or equal to 30 degrees (Choice A), unless specifically ordered otherwise by the physician. Grouping multiple nursing activities (Choice B) like turning, bathing, linen change, and suctioning will dramatically increase intracranial pressure for an extended amount of time. To minimize increase in intracranial pressure, nursing activities should be planned to give the client 30-60 minute breaks between activities. The intracranial pressure will increase with any activity, but the pressure will have an opportunity to decrease to safer levels if activities are not clustered. Positioning to prevent an increase in intracranial pressure is focused on alignment of the head and neck and elevation of the head of bed at 30 degrees, not the legs (Choice D).

Kevin, 23 Years Old, Was Admitted for Closed Head Injury