Aclient who is unconscious has a nursing diagnosis of ineffective cerebral tissue perfusion related to cerebral tissue swelling. Which of the following nursing interventions should be included in the plan of care?
A)Keep the head of the bed elevated to 30 degrees.
B)Position the client with the knees and hips flexed.
C)Encourage coughing and deep breathing to improve oxygenation.
D)Cluster nursing interventions to provide uninterrupted rest periods.

Question

Quizplus · Accepted Answer

The client with increased intracranial pressure (ICP) should be maintained in the head-up position to help reduce ICP. Flexion of the hips and knees increases abdominal pressure, which increases ICP. Because the stimulation associated with nursing interventions increases ICP, clustering interventions will progressively elevate ICP. Coughing increases intrathoracic pressure and ICP.

Aclient Who Is Unconscious Has a Nursing Diagnosis of Ineffective