Question

The nurse is caring for a patient with increased intracranial pressure. Which actions should the nurse perform to promote optimal outcomes for the patient? Select all that apply.

-Maintain fluid balance and assess osmolality.

-Maintain intubation and mechanical ventilation.

-Lower the head of the bed and turn the patient to one side.

-Wait for the respiration to improve before beginning with ventilation.

-Elevate the head of the bed to 30 degrees with the head in a neutral position.

Answer 1

To promote optimal outcomes for a patient with increased intracranial pressure, the nurse should maintain fluid balance and assess osmolality, maintain intubation and mechanical ventilation if necessary, and elevate the head of the bed to 30 degrees with the head in a neutral position.

Step-by-step explanation:

To promote optimal outcomes for a patient with increased intracranial pressure, the nurse should perform the following actions:

1. Maintain fluid balance and assess osmolality: Fluid balance should be carefully monitored to prevent dehydration or fluid overload. Osmolality refers to the concentration of solutes in the blood and should be assessed regularly to ensure it stays within a normal range.
2. Maintain intubation and mechanical ventilation: If the patient is experiencing breathing difficulties, intubation and mechanical ventilation may be necessary to ensure adequate oxygenation.
3. Elevate the head of the bed to 30 degrees with the head in a neutral position: Elevating the head of the bed to a 30-degree angle with the head in a neutral position helps to reduce intracranial pressure by promoting venous drainage.