Question

A nurse is caring for a client who had a stroke 6 hr ago. Which of the following interventions should the nurse implement to reduce the risk of increased intracranial pressure (ICP)? A. Flex the clients neck forward B. Group several nursing activities to be completed at once C. Limit suctioning the client's airway to 30 seconds at a time D. Place the client in a quiet environment

Answer 1

D.

Step-by-step explanation:

When caring for a client who has had a stroke and is at risk for increased intracranial pressure (ICP), it is essential to create an environment that minimizes stimulation and stress on the brain. A quiet environment helps reduce sensory input and can help lower the risk of further increasing ICP. Noise and excessive activity can lead to stress and potentially exacerbate the client's condition.

The other options are not appropriate for reducing the risk of increased ICP:

A. Flexing the client's neck forward can obstruct blood flow and increase pressure in the brain, potentially worsening the condition.

B. Grouping nursing activities to be completed at once might help with time management but does not directly address the risk of increased ICP.

C. Limiting suctioning the client's airway to 30 seconds at a time is a good practice to prevent hypoxia, but it does not directly address ICP.