nclex question... please read n comment

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pt. with evacuation of subdural hematoma.. what would you do to reduce the risk of increased ICP:

A. ELEVATE THE HEAD OF THE BED 90 DEGREES

B. SUCTION ONCE A SHIFT

C. ADMINISTER STOOL SOFTNERS

D. ENCOURAGE ORAL FLUID INTAKE

PLEASE give ur answers and valuable rationales..

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Disregard my last ...just read in my book that suction nor cough and sneezing is good. My notes are messy. Correct me if I'm wrong. So um. Idk my input anymore.

Edit

Me n my mom chose C. Cuz 90 is a lot, suction isn't good, n fluid intake I believe is unnecessary.

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I would answer elevate HOB ..As I am thinking of modified trendelenburg pos wc is accepted to rule out /prevent increase ICP.elevating at 90 degree I think wouldn't hurt the patient. I would not suction - this is my thought for any head trauma or injury as it further damage causing penetration unless prescribed. I won't pick stool softener too because I need a doctor's order I won't pick encourage fluid intake too - I would pick this if doctor is giving any osmotic diuretic meds. It's what I recall from my saunders book.. I'm not sure if I am correct ... But that is how I would answer ... I'd choose bet elevate or increase fluid.. Please correct me if I am wrong.

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I would put A or C. A so that the person doesnt have increased pressure or C to prevent straining to increase icp but more so A.

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the answer is to give stool softeners bcoz fluids suction and hob above 30 all increases risk of ICP

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Guys in nclex, you have everything in the world.So assume stool softener has already been ordered by the HCP.

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Straining can increase ICP so might as well administer laxatives.

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I'm not gonna read the comments to be fair. I'd say C. give stool softeners because A. It should be only semi fowlers to promote reduction in increased ICP, B. Suction also would result in increasing ICP and so would D. too much fluid already why would you add to the body.

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I think C to reduce the risk of increasing the iCP

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I would elevate the head of the bed but administering stool softners sounds good as well.Ugggghh this is why I hate N clex its always 2 answers left n they both always look right(lol)

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

elevating the HOB to 90 degrees isn't the intervention. As someone already mentioned >30 degrees can increase the ICP and CPP (cerebral perfusion pressure). Straining for a BM and suctioning increase ICP dramatically. You do not encourage fluids on a head injury.

I think it is C

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Medications (stool softeners, laxatives) are parts of the medical plan of care and must be prescribed by the physician. NCLEX is not interested in that. It wants to know what you, the NURSE, will implement as part of your NURSING plan of care.

You know that your patient will have a problem if she has an elevated ICP. So of the two answers that are not parts of the medical plan of care, which will increase ICP (coughing, which you will surely provoke if you suction her) and which will decrease it (elevating the head of the bed, which promotes venous drainage (subdural hematoma, remember?) ? Now you have your answer.

I have never, ever heard that elevating the head of the bed increases ICP, quite the opposite. If so, references?

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