nclex question...can someone please answer this question?

[princess007]

i was doing some questions online and found this question the answer they show there i totally disagree with it.what do you guys think is the right answer? and if possible why you that is the right answer please..thanks soo much

A nursing assessment on a male patient indicates that he is showing evidence of increased intracranial pressure. The first nursing action is to

Answer=

A)Place him in high-Fowler`s position.

B) Place him on his side.

C) Have him cough and deep breathe.

[medicrn13]

A.

Placing them in a High-Fowler's position decreases ICP by decreasing venous pooling and allowing blood to drain from the cranial vault.( I think that's correct anyway, someone correct me please!)

Coughing or sneezing can increase ICP, deep breathing does nothing for ICP although hyperventilation does by decreasing CO2 in the body which constricts blood vessels. Laying them on their side also doesn't really solve the problem.

[MedSurgeMess]

Same as 1st 2 posts

[mofokittykat]

Elevate HOB 30-45 degrees with head in neutral position???

[Virgo_RN, BSN, RN]

I would think it would be A....what did they say the answer was?

[RNman09]

I wouldn't pick (a) because a high fowlers position is 60-90 degrees. This position is for supratentorial surgeries, semi fowlers (30-45-degrees), I could be wrong. Side lying is for infratentorial surgeries because of incision site. But your question doesn't say post op so I'm curious about the answer.

[morte, LPN, LVN]

was there a fourth option?

[Silverdragon102, BSN]

moved to the NCLEX forum

[afi06]

To answer you question I am going to make reference to Saunders page 1029 I am hoping you have one, under interventions it mentions that: 1) Elevate the HOB 30-40 degrees as prescribed,2) instruct the client to avoid straining activities,such as coughing and sneezing, to now answer your question option A would have been the right answer butthe postion you have up there indicates high fowlers not semi fowlers,I would always encourage you to always use a well reliable textbook to support some of your curiousities because some of the questions posted on some websites have some wrong informations but they are good websites but follow my advise because I have been there before and also know your contents too,good luck with your studies.

[princess007]

A.

Placing them in a High-Fowler's position decreases ICP by decreasing venous pooling and allowing blood to drain from the cranial vault.( I think that's correct anyway, someone correct me please!)

Coughing or sneezing can increase ICP, deep breathing does nothing for ICP although hyperventilation does by decreasing CO2 in the body which constricts blood vessels. Laying them on their side also doesn't really solve the problem.

thank you for your answer..thats what i picked but it said the correct answer is to ask the pt. cough and deep breathe..thats why i posted this question because i m preparing for my nclex and didnt want to answer it wrong if i get a question like this there...

[Virgo_RN, BSN, RN]

That is incorrect. I would use a different study guide, were I you.

[EDRN-2010]

Well out of the choices, since the correct first thing to do is put in semi-fowlers position but since that is not a choice I would pick the tell patient to avoid coughing etc. It is the most correct answer out of the choices. Did the question specifically say "first response" or "initial action"? Sometimes the nclex questions say which would be the nurses "best response" or "most appropriate nursing action" - meaning it is not always the initial thing the nurse will do. My professor always says that sometimes the best answer is not one of the options, so it is important that we can identify the next best thing and weed out the wrong interventions. I have never heard of high fowlers with increased ICP - just semi fowlers and neck in neutral. I think wherever you got the question from is a good resource but it would certainly be better if it gave rationales. Sometimes saunders sucks in that the best answer is usually an option so you don't ever have to think about what the next best answer would be, seems like this might be a little more challenging.