A patient's neurological status deteriorates over hours, and a craniotomy is performed to evacuate the hematoma. Which nursing intervention is indicated to help decrease the threat of increased intracranial pressure?
a. Elevate the head of the bed 30 degrees.
b. Cluster nursing interventions to provide uninterrupted periods of rest.
c. Teach him to cough and deep breathe to prevent the necessity for suctioning.
d. Teach him to hold his breath and bear down while repositioning in bed.
Question 2
Mrs. Fawcett is a 70-year-old woman who has a diagnosis of emphysema and who receives long-term oxygen therapy.
She has presented to the emergency department because she states that she is experiencing an exacerbation of her chronic obstructive pulmonary disease (COPD), and she is in visible respiratory distress. How can the nurse best assess Mrs. Fawcett's dyspnea?
A) Observe her activity tolerance and assess her skin tone.
B) Measure her SpO2 by pulse oximetry and assess her respiratory rate.
C) Auscultate her anterior and posterior lung fields.
D) Ask her to rate her shortness of breath on a scale of 0 to 10.
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