# Situation: A 24-year-old man is transferred to the neurosurgical ward 2 days after a motorcycle crash. Computed tomography (CT) showed a small frontal contusion and a basilar skull fracture, with no hematoma needing surgery. His cervical spine has been cleared. He is drowsy but easily roused and slightly confused. At 08:00 he needs a bed bath, a dressing change on his scalp wound, and repositioning. He has not passed stool for 3 days. The physician has ordered measures to prevent a rise in intracranial pressure (ICP). Which plan should the nurse follow?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=630422  
> language: ko  
> subject: Nursing Practice IV — Care of Clients with Problems in Nutrition and Gastrointestinal, Metabolism and Endocrine, Perception and Coordination

## 문제

Situation: A 24-year-old man is transferred to the neurosurgical ward 2 days after a motorcycle crash. Computed tomography (CT) showed a small frontal contusion and a basilar skull fracture, with no hematoma needing surgery. His cervical spine has been cleared. He is drowsy but easily roused and slightly confused.

At 08:00 he needs a bed bath, a dressing change on his scalp wound, and repositioning. He has not passed stool for 3 days. The physician has ordered measures to prevent a rise in intracranial pressure (ICP). Which plan should the nurse follow?

## 보기

1. Space the tasks with rest periods; give the ordered stool softener **✔ 정답**
2. Do all three tasks together, then let him rest undisturbed for 3 hours
3. Do the tasks together, then give a tap-water enema for the constipation
4. Space the tasks, and have him push up in bed with his heels in between

**정답: 1**

## 해설

Clustering several stimulating procedures raises intracranial pressure, so care is spaced with rest periods between tasks. Straining is a Valsalva maneuver that also raises it, so constipation is managed with stool softeners, and the client is not asked to push himself up in bed. Each distractor contains one action that raises intracranial pressure.

## 심화 해설

The plan that protects intracranial pressure
At 08:00 he needs a bed bath, a scalp dressing change, and repositioning, and he has not passed stool for 3 days. Clustering several stimulating procedures raises intracranial pressure (ICP), so care is spaced with rest periods between tasks. Straining is a Valsalva maneuver that also raises ICP, so constipation is managed with the ordered stool softener. The correct plan is to space the tasks with rest periods and give the stool softener.

How care activities affect ICP
Inside the rigid skull, any increase in blood, brain tissue, or CSF volume raises pressure once compensation is exhausted. An injured brain has little reserve. Stimulating activities such as bathing, dressing changes, turning, and suctioning each cause a temporary rise in ICP. When they are performed back to back, these rises stack before pressure has time to return to baseline, producing a sustained elevation. Spacing them allows recovery in between. The Valsalva maneuver, which occurs with straining at stool, pushing up in bed, or forceful coughing, raises intrathoracic pressure, impedes venous return from the head, and raises ICP.

| Plan | ICP-raising element | Verdict |
| --- | --- | --- |
| Space tasks; give stool softener | None | Correct |
| Cluster tasks, then rest 3 hours | Clustering stimulating procedures | Incorrect |
| Cluster tasks, then tap-water enema | Clustering and straining | Incorrect |
| Space tasks; push up with heels | Valsalva-type effort | Incorrect |

Why each distractor fails
Each distractor contains one action that raises intracranial pressure. A long rest afterward does not offset the rise caused by clustering several stimulating procedures. A tap-water enema after clustered care adds straining and vagal stimulation; stool softeners are used instead. Pushing up in bed with the heels is an isometric, Valsalva-type effort, so even though spacing is right, this plan still raises ICP; staff reposition the client using a lift sheet.

Other ICP precautions
The head of the bed is elevated as ordered with the head in a neutral midline position, avoiding neck flexion or rotation that obstructs venous drainage. The environment is kept calm, pain and fever are controlled, and coughing and suctioning are minimized. The nurse monitors level of consciousness, pupils, and vital signs before and after care.

Exam takeaway
Key point For clients at risk of raised ICP: space care, prevent straining with stool softeners, avoid enemas and isometric pushing, keep the head midline and elevated.

## 임상 시나리오

Planning Care to Limit ICP RisesSpace activities and prevent straining
Clustering stimulating care such as bathing, dressing changes, and repositioning stacks temporary rises in intracranial pressure. Tasks are spaced with rest periods between them.

Straining is a Valsalva maneuver that raises ICP, so constipation is treated with a stool softener. The client is repositioned by staff rather than pushing up with his heels.

CautionAvoid enemas, isometric effort, and neck flexion. Keep the head midline and elevated as ordered.

## 핵심 개념

- **Intracranial pressure** — The pressure inside the skull exerted by brain tissue, blood, and cerebrospinal fluid.
- **Valsalva maneuver** — Forced exhalation against a closed airway, as in straining, which raises intrathoracic and intracranial pressure.
- **Clustering care** — Performing several nursing activities in a row without rest, which can raise intracranial pressure.
- **Stool softener** — A medicine that keeps stool soft to prevent straining.

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