Difficulty: Medium
Average Score: 67%
Simulated
The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a patient with an acute head injury. Which actions should the nurse take to achieve this goal?
Correct answer
A,B,D
Rationale
Elevating the head of the bed aids venous drainage, serial assessments monitor ICP changes, and sedatives/pain medications reduce cerebral metabolic rate, all helping maintain normal ICP.