Author Question: When caring for a patient after a head injury, the nurse would be most concerned with assessment ... (Read 27 times)

sc00by25 · **on:** Jul 22, 2018

When caring for a patient after a head injury, the nurse would be most concerned with assessment findings which included respiratory changes along with what other findings?

a. Hypertension and bradycardia
b. Hypertension and tachycardia
c. Hypotension and bradycardia
d. Hypotension and tachycardia

Question 2

The nurse is caring for a patient with increased intracranial pressure. Which action is considered unsafe?

a. Aligning the neck with the body
b. Clustering many nursing activities
c. Elevating the head of the bed 30 degrees
d. Providing stool softeners or laxatives as ordered

pami445 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: A
Hypertension with widening pulse pressure, bradycardia, and respiratory changes are the ominous late signs of increased intracranial pressure and indications of impending herniation (Cushing's triad). It is bradycardia, not tachycardia, which is the component of this ominous triad. It is hypertension, not hypotension, which is the component of this ominous triad.

Answer to Question 2

ANS: B
It is important to minimize stress and activities that could increase intracranial pressure. Combining many nursing activities could increase oxygen demand and intracranial pressure. This would not be safe. Interventions which can promote venous outflow can help decrease intracranial pressure. The stress of constipation or bowel movements can increase intracranial pressure; stool softeners or laxatives can minimize this.