Question

"The nurse is planning the care for a patient with increased intracranial pressure (ICP). What actions should the nurse plan to perform to provide the most comfort for the patient? Select all that apply.

-Minimize procedures that can produce agitation.

-Observe the patient for signs of agitation or irritation.

-Teach the patient's family about increasing stimulation.

-Make the patient remain in a quiet and calm environment.

-Allow the patient's family to visit the patient more often."

Answer 1

To provide comfort for a patient with increased intracranial pressure, nurses should minimize agitating procedures, monitor for signs of agitation, and maintain a quiet and calm environment, rather than teaching the family about increasing stimulation or allowing more frequent family visits.

Step-by-step explanation:

The care for a patient with increased intracranial pressure (ICP) involves several focused actions to ensure patient comfort and safety. These actions include:

• Minimize procedures that can produce agitation.
• Observe the patient for signs of agitation or irritation.
• Make the patient remain in a quiet and calm environment.

Contrary to increasing stimulation, it is generally recommended to reduce sensory overload to minimize the risk of further increasing ICP. Monitoring for signs of agitation is important as it may indicate a need to adjust care to prevent an increase in ICP. Promoting a quiet and calm environment helps in limiting external stimuli that can contribute to ICP elevation. While family involvement is important, the frequency and duration of visits should be balanced to avoid overstimulation of the patient.