Editing Anatomy and Physiology – RN Practice Questions (section)

==Question 2==
A nurse is caring for a patient with a severe traumatic brain injury. Which interventions should the nurse include to limit further increases in intracranial pressure? '''Select all that apply.'''
# Maintain the head of the bed elevated approximately 30 degrees.
# Keep the head and neck in a neutral midline position.
# Cluster nursing care activities to allow uninterrupted rest periods.
# Suction the endotracheal tube every hour on a routine schedule.
# Administer a prescribed stool softener to prevent straining.
# Infuse 0.45% sodium chloride to maintain hydration.

'''Answer:''' 1, 2, 3, and 5 (A, B, C, E).

''Rationale:'' The Monro-Kellie doctrine holds that the rigid skull contains a fixed volume of brain tissue, blood, and cerebrospinal fluid, so anything that impairs venous outflow or adds volume raises intracranial pressure. Elevating the head about 30 degrees and keeping the head midline promote jugular venous drainage. Clustering care limits repeated stimulation, each episode of which transiently raises pressure. Stool softeners prevent the Valsalva maneuver, which raises intrathoracic pressure and impedes cerebral venous return. Option 4 is incorrect because suctioning raises intracranial pressure and is performed only when indicated, briefly, and with preoxygenation, never on a routine hourly schedule. Option 6 is incorrect because 0.45% sodium chloride is hypotonic and shifts water into brain cells, worsening cerebral edema.