问题 单项选择题

The nurse is caring for a comatose client who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)

A. Suction the airway every hour and as needed.
B. Elevate the head of the bed 15 to 30 degrees.
C. Turn the client and change his position every 2 hours.
D. Maintain a well-lit room.

答案

参考答案:B

解析:To facilitate venous drainage and avoid jugular compression, the nurse should elevate the head of the bed 15 to 30 degrees. Clients with increased ICP poorly tolerate suctioning and shouldn’t be suctioned on a regular basis. Turning from side to side increases the risk of jugular compression and rises in ICP, so turning and changing positions should be avoided. The room should be kept quiet and dimly lit.

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