While Caring for a Patient with a Closed Head Injury,the

question 24

Multiple Choice

While caring for a patient with a closed head injury,the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg,heart rate 60 beats/min,respirations 18 breaths/min,and a temperature of 102°F.To reduce the risk of increased intracranial pressure (ICP) in this patient,what is (are) the priority nursing action(s) ?

• A) Ensure adequate periods of rest between nursing interventions.
• B) Insert an oral airway and monitor respiratory rate and depth.
• C) Maintain neutral head alignment and avoid extreme hip flexion.
• D) Reduce ambient room temperature and administer antipyretics.

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