Which of the following nursing interventions will help prevent a further increase in ICP?

Correct Answer: C

Rationale: Elevating the head of the bed is the correct answer because it helps to promote venous drainage, reduce cerebral edema, and decrease intracranial pressure (ICP). By positioning the patient with the head elevated, gravity assists in preventing further increases in ICP. Encouraging fluids may lead to fluid overload and exacerbate cerebral edema. Providing physical therapy and frequent repositioning may increase ICP by causing unnecessary movement and potential strain on the patient's head and neck.

Correct Answer: B

Rationale: The correct answer is B: "I will press the button whenever I feel pain." This answer demonstrates understanding of how patient-controlled analgesia (PCA) works, where the client self-administers medication when needed for pain relief. Option A is incorrect as the machine is programmed with lockout intervals to prevent overdosing. Option C is incorrect as the client should only press the button when experiencing pain, not on a fixed schedule. Option D is incorrect as PCA does not guarantee complete pain elimination. The key in PCA is empowering the client to self-administer medication based on their pain level.

Correct Answer: D

Rationale: The correct answer is D. Bacterial meningitis alters intracranial physiology by causing cerebral edema, raised intracranial pressure, and increased permeability of the blood-brain barrier. Cerebral edema is the accumulation of fluid in the brain tissue, leading to increased pressure. Raised intracranial pressure occurs due to the inflammation and swelling caused by the infection. Increased permeability of the blood-brain barrier allows substances to pass through that would normally be blocked, contributing to the inflammatory response. Therefore, all of these changes are interconnected and commonly observed in bacterial meningitis cases. Choices A, B, and C individually describe specific alterations seen in bacterial meningitis but do not encompass the full spectrum of changes that occur, making them incorrect options.

Correct Answer: B

Rationale: Correct Answer: B: Calcium should be avoided Rationale: 1. Calcium is an essential mineral for bone health, especially important for individuals with limited mobility like Richard. 2. Avoiding calcium can lead to bone weakening and increase the risk of fractures. 3. Nursing care plans should include adequate calcium intake to support bone health. 4. Therefore, avoiding calcium is not a recommended nutritional consideration. Summary of Incorrect Choices: A: The diet should be semisolid to facilitate the passage of food - This is important for individuals with swallowing difficulties. C: The patient should be sitting in an upright position during feeding - This aids in proper digestion and reduces the risk of aspiration. D: Thick fluids should be encouraged to provide additional calories - Thick fluids may increase the risk of aspiration in patients with neurological conditions.

Correct Answer: C

Rationale: The correct answer is C: To rule out cholinergic crisis caused by Neostigmine. Edrophonium HCL is a fast-acting cholinesterase inhibitor used to differentiate between myasthenic crisis and cholinergic crisis. If the patient's weakness improves after administration of edrophonium, it indicates that the weakness was due to myasthenia gravis and not cholinergic crisis caused by excessive neostigmine. Choice A is incorrect because there is no synergestic effect between neostigmine and edrophonium. Choice B is incorrect as resistance to neostigmine is not a valid reason for ordering edrophonium. Choice D is incorrect because edrophonium is used for differential diagnosis, not for confirming the diagnosis of myasthenia gravis.