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 ICP?

a) Flex the client's neck forward.

b) Group several nursing activities to be completed at one time.

c) Limit suctioning the client's airway to 30 seconds at a time.

d) Place the client in a quiet environment.

Answer 1

To reduce the risk of increased ICP in a client who had a stroke, a nurse should flex the client's neck forward, group nursing activities, and limit suctioning the client's airway.

Step-by-step explanation:

When caring for a client who had a stroke, the nurse should implement interventions to reduce the risk of increased intracranial pressure (ICP). One of the interventions is to flex the client's neck forward, which helps promote venous drainage from the brain and reduces ICP. Another intervention is to group several nursing activities to be completed at one time to minimize environmental stimuli and reduce stress, which can contribute to increased ICP. Lastly, limiting suctioning of the client's airway to 30 seconds at a time helps prevent hypoxia and excessive increase in ICP.

In contrast, placing the client in a quiet environment is not a direct intervention to reduce ICP. While providing a quiet environment may promote rest and reduce stimulation, it does not directly address factors that increase ICP.