A patient with severe traumatic brain injury exhibits signs of acutely increased intracranial pressure, including bradycardia, systolic hypertension and irregular respirations. Which nursing action should be avoided in the care of this patient?

1. A

   Keeping the head in a neutral, midline position

2. B

   Elevating the head of the bed 15 to 30 degrees

3. C

   Changing the position side-to-side frequently

4. D

   Providing uninterrupted periods of rest with careful clustering of care

Appeared in: NORCET-11 Prelims

Explanation

• Frequent side-to-side turning increases stimulation and can raise intracranial pressure.
• Minimizing movement and stimulation is essential in acute ICP management.
• Other interventions (neutral head, bed elevation, clustering care) help reduce or stabilize ICP.

Why Other Options Were Wrong

• Option A: Neutral, midline head positioning promotes venous drainage and is recommended for ICP management.
• Option B: Elevating the head of the bed 15 to 30 degrees helps reduce ICP by improving venous outflow.
• Option D: Providing uninterrupted rest and clustering care minimizes stimulation and prevents ICP spikes.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Nursing interventions to avoid in patients with increased intracranial pressure in acute care settings.
• Nurses must avoid unnecessary stimulation in patients with raised ICP to prevent secondary brain injury.
• Monitoring for signs of increased ICP and adjusting care accordingly is critical for patient safety.
• What if? If the patient is not turned at all, risk of pressure ulcers increases; turning should be done only as needed and with great care, not frequently.

How to Approach the Question

• Identify the clinical scenario: acute increased ICP after traumatic brain injury.
• Recall standard nursing interventions for ICP management.
• Eliminate options that are recommended for ICP control (neutral head, bed elevation, clustering care).
• Recognize that frequent side-to-side turning is the only action that can worsen ICP in this context.

Concept Tested & Keywords

• Concept Tested: Nursing interventions to avoid in patients with increased intracranial pressure
• Stem keywords: severe traumatic brain injury, acutely increased intracranial pressure, bradycardia, systolic hypertension, irregular respirations
• Lead-in keywords: should be avoided
• Clinical cues: Signs of increased ICP: bradycardia, hypertension, irregular respirations

Question ID

QzUonUaxnjsBdWrU7M6DQl

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 2 Part 2 pp. 37-39, 34-36