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1. Question
A client has suffered a severe traumatic brain injury and is being treated in the ICU. Which of the following interventions does the nurse anticipate to control intracranial pressure? Select all that apply.
Correct
Option A, C and D is the correct answers;
Rationale: A, C, and D: If a client has suffered a traumatic brain injury and is being treated in the ICU, the nurse should expect to elevate the head of the bed and keep the client’s head in neutral alignment. The nurse will likely administer oxygen to maintain the PaO2 at > 90 mm Hg (85 mm Hg is hypoxic) and will administer sedation to prevent or reduce agitation. Additionally, cerebral perfusion pressure should be maintained at > 70 mm Hg and body temperature maintained within normal limits.
Incorrect
Option A, C and D is the correct answers;
Rationale: A, C, and D: If a client has suffered a traumatic brain injury and is being treated in the ICU, the nurse should expect to elevate the head of the bed and keep the client’s head in neutral alignment. The nurse will likely administer oxygen to maintain the PaO2 at > 90 mm Hg (85 mm Hg is hypoxic) and will administer sedation to prevent or reduce agitation. Additionally, cerebral perfusion pressure should be maintained at > 70 mm Hg and body temperature maintained within normal limits.
Traumatic brain injury is the most serious form of head injury. The most common causes of traumatic brain injury are motor vehicle crashes, violence, and falls. Groups at highest risk for traumatic brain injury are persons age 15 to 24 years and males, who suffer traumatic brain injury at a rate almost twice that of females.
The very young (under 5) and the very old (over 75) are also at increased risk. It is estimated that 5.3 million Americans today are living with a disability as a result of a traumatic brain injury.
