Question

While the nurse performs ROM on an unconscious patient with increased ICP, the patient experiences severe decerebrate posturing reflexes. The nurse should

a. use restraints to protect the patient from injury
b. administer CNS depressants to lightly sedate the patient
c. perform the exercises less frequently because posturing can increase ICP
d. continue the exercises because they are necessary to maintain musculoskeletal function

Answer 1

The nurse should use restraints to protect the patient from injury.

Step-by-step explanation:

When performing Range of Motion (ROM) exercises on an unconscious patient with increased Intracranial Pressure (ICP), it is important to be cautious of the patient's reflex responses. Severe decerebrate posturing reflexes, such as the rigid body posture known as opisthotonos, can indicate neurological issues.

The nurse should a. use restraints to protect the patient from injury in this situation. The posturing reflexes can cause the patient to forcefully extend their arms and legs, which can lead to accidental self-injury.

Using restraints is necessary to ensure the safety of the patient and prevent further harm.