Question

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)?

a. Elevate the head of the bed to 30 degrees.
b. Administer intravenous hypertonic saline.
c. Encourage the client to perform Valsalva maneuvers.
d. Administer anticoagulant therapy.

Answer 1

To reduce increased intracranial pressure in a stroke patient, the best intervention is to elevate the head of the bed to 30 degrees. Other measures include administering intravenous hypertonic saline with caution, and avoiding Valsalva maneuvers. Anticoagulant therapy is not typically indicated immediately after a stroke due to the risk of hemorrhage.

Step-by-step explanation:

To reduce the risk of increased intracranial pressure (ICP) in a client who had a stroke 6 hours ago, the nurse should implement the following interventions:

• Elevate the head of the bed to 30 degrees: This helps to enhance venous outflow from the brain and reduce ICP.
• Administer intravenous hypertonic saline: Hypertonic saline can reduce cerebral edema and lower ICP when used judiciously.
• Encourage the client to avoid Valsalva maneuvers: These maneuvers can increase ICP and should be avoided.
• Administer anticoagulant therapy only if indicated and with caution: Anticoagulation may be considered in certain types of strokes, but not typically in the immediate acute phase and requires careful consideration due to the risk of hemorrhage.

The most appropriate intervention from the provided options to reduce the risk of increased ICP is to elevate the head of the bed to 30 degrees.