While caring for a client with increased intracranial pressure ...

[jwb375]

While caring for a client with increased intracranial pressure (IICP), a family member asks to assist. Which interventions are appropriate for the nurse to teach the family member regarding this client's care?
 
  Select all that apply.
  A) The head of the bed should be elevated to 30 degrees.
  B) The client should remain in a supine position.
  C) The family should use slow, gentle movements when repositioning the client.
  D) The client should be repositioned as needed.
  E) Patients with ICP should remain in a stationary position.

Question 2

The nurse, caring for older school-age client recovering from an appendectomy, is preparing to help the family ambulate the child for the first time after surgery. Which non-pharmacological nursing strategy would be appropriate for this client?
 
  A) A warm, moist pack over the site of the incision
  B) A splint pillow against the abdomen when moving or coughing
  C) Administering appropriate narcotic analgesics
  D) An ice pack over the site of the incision

[Missbam101]

Answer to Question 1

Answer: A, C, D

Patients with increased ICP should be repositioned slowly and with gentle movements, because rapid changes can cause the pressure to increase. The head of the bed should be elevated. The degree depends on the reaction of the client to the position; 30 degrees is usually appropriate, but this can vary by the client. Patients with IICP must not remain stationary, but position changes should be done less frequently than for other clients because turning, skin care, and passive range of motion exercises can elicit posturing, which also causes increased ICP.

Answer to Question 2

Answer: B

A splint pillow placed on the abdomen is a non-pharmacological strategy to decrease discomfort after an appendectomy. Heat and ice are not used on the incision area, as they can impair the healing process of the wound. Administering a narcotic is considered a pharmacological nursing strategy.