Question

Which of the following interventions should the nurse perform for a patient who is at risk for increased intracranial pressure?

A) Assessing the patient's gag reflex
B) Limiting suctioning to less than 30 seconds
C) Keeping the patient's bed in the high Fowler's position
D) Positioning pillows to hyperextend the neck

Answer 1

Option D. For a patient at risk for increased intracranial pressure, the nurse should limit suctioning to less than 30 seconds to help control the patient's ICP, while avoiding positions like hyperextending the neck which could worsen the condition.

Step-by-step explanation:

For a patient who is at risk for increased intracranial pressure (ICP), the nurse should perform specific interventions tailored to manage and minimize the risk. The correct intervention among those listed is B) Limiting suctioning to less than 30 seconds. Excessive suctioning duration can lead to increased ICP due to hypoxemia or the triggering of a vagal response.

Furthermore, keeping the head of the bed elevated 30 degrees is generally recommended in patients at risk of increased ICP to facilitate venous drainage, so C) Keeping the patient's bed in the high Fowler's position is potentially incorrect depending on the specific angle referenced by 'high Fowler's' as it may be too steep. A) Assessing the patient’s gag reflex is often part of the neurological assessment but does not directly contribute to managing ICP. Lastly, D) Positioning pillows to hyperextend the neck is inappropriate because this can actually impair venous drainage from the brain and potentially increase ICP.