Question

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity?

1.Blowing the nose
2.Isometric exercises
3.Coughing vigorously
4.Exhaling during repositioning

Answer 1

The client understands how to prevent increases in intracranial pressure if they are observed exhaling during repositioning, which helps to maintain consistent cerebrospinal fluid pressure and avoid further brain injury.

Step-by-step explanation:

The nurse can determine that a client recovering from a head injury understands measures to prevent elevations in intracranial pressure if the nurse observes the client exhaling during repositioning. This is because holding one's breath can cause the Valsalva maneuver, which can increase intracranial pressure. On the other hand, exhaling during movement or exertion helps to keep intracranial pressure low. This is important for a client with a head injury, as an increase in intracranial pressure can lead to brain damage or exacerbate existing injuries.

The consistency of cerebrospinal fluid pressure, which is normally between 5-12 mm Hg, is crucial to protect the brain by providing a flotation mechanism that prevents it from resting on the skull, which can cause headaches, constricted blood flow, and even serious damage. Understanding how to maintain this delicate balance is vital in the care of patients with head injuries. By exhaling during repositioning, the client is demonstrating an understanding of how to prevent pressure increases, which is a positive sign of effective patient education and involvement in their own recovery process.