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The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

2 Rationale: The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing BP 2. Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP 3. Decreasing temperature, increasing pulse, decreasing respirations, increasing BP 4. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

4 Rationale: A change in vital signs may be a late sign of increased ICP. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise.

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply. 1. Pad the bed's side rails. 2. Place an airway at the bedside. 3. Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside. 5. Tape a padded tongue blade to the wall at the head of the bed.

1,2,3,4 Rationale: The nurse should plan seizure precautions for a client with a seizure disorder. The precautions include padded side rails and an airway (to maintain airway patency if required), and oxygen and suction equipment at the bedside. Attempts to force a padded tongue blade between clenched teeth may result in injury to the teeth and mouth; therefore, a padded tongue blade is not placed at the bedside.