NCLEX-RN

Category - Physiological

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A nurse is making a nursing care plan for a client with increased intracranial pressure. The nurse includes the following actions in her plan of care except:

Raising the head of bed 30 to 40 degrees
Keep the head in neutral position
Environmental stimuli are decreased
Encourage Valsalva’s maneuver for 15 minutes, every 2 hours

Explanation

Answer: D - The client must avoid Valsalva’s maneuver, straining, coughing, and sneezing, as these can increase the intracranial pressure. Raising the head of the bed 30 to 40 degrees, keeping the head in neutral position and maintaining a calm and quiet environment prevents the increase of intracranial pressure.

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