A nurse is caring for a client with a subarachnoid hemorrhage who has an intracranial pressure (ICP) monitor in place. The client's ICP readings have been fluctuating between 18-22 mmHg over the past hour. Which nursing action should be the priority?

1 Administer prescribed mannitol 1 g/kg IV bolus immediately
2 Position the client in Trendelenburg position to improve cerebral perfusion
3 Elevate the head of the bed to 30 degrees and ensure proper neck alignment ✓ 정답
4 Increase the rate of IV fluids to maintain adequate blood pressure

해설

Proper positioning (head of bed at 30 degrees with neck alignment) is the priority nursing intervention for elevated ICP as it promotes venous drainage and reduces intracranial pressure. Other options are less immediate or require physician orders.

같은 주제 다음 문제A nurse is caring for a client who sustained a severe traumatic brain injury 48 hours ago.…

심화 해설

Understanding the Clinical Scenario
The client has a subarachnoid hemorrhage with an ICP monitor showing readings of 18-22 mmHg. This is a critical situation because sustained ICP above the normal threshold (typically

임상 시나리오

ICP Crisis: First-Line PositioningElevate Head Before Medications

Elevate the head of bed to 30 degrees and maintain neutral neck alignment to maximize cerebral venous outflow. This non-invasive intervention can lower ICP by 2-5 mmHg within minutes.

Avoid hip flexion >90 degrees and ensure the cervical collar or tracheostomy ties are not too tight to prevent jugular vein compression.

Caution

If ICP remains sustained above 20-22 mmHg despite positioning, prepare to administer mannitol or hypertonic saline as prescribed. Never place a patient with elevated ICP in Trendelenburg position.

핵심 개념

Intracranial Pressure (ICP) — The pressure inside the skull exerted by brain tissue, blood, and cerebrospinal fluid; normal is 5-15 mmHg.
Subarachnoid Hemorrhage — Bleeding into the subarachnoid space, often causing severe headache and increased risk of vasospasm and hydrocephalus.
Cerebral Perfusion Pressure (CPP) — The net pressure gradient driving cerebral blood flow; calculated as MAP minus ICP, with a target typically >60-70 mmHg.
Mannitol — An osmotic diuretic used to reduce cerebral edema and ICP by drawing fluid from brain tissue into the vasculature.

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A nurse is caring for a client with a subarachnoid hemorrhage who has an intracranial pressure (ICP) monitor in place. The client's ICP readings have been fluctuating between 18-22 mmHg over the past hour. Which nursing action should be the priority?

심화 해설

임상 시나리오

핵심 개념

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