Question

The critical care nurse is observing a senior nursing student performing client care to a client after a craniotomy. Which action by the student would require nurse intervention? A. The student elevates the head of the bed \(30^{\circ}\). B. The student instructs the client to cough forcefully. C. The student is preparing to perform a cranial dressing change with sterile gloves. D. When turning the client, the student keeps the head in a neutral position.

Short answer

A. Elevating the head of the bed to \(30^{\circ}\) B. Instructing the client to cough forcefully C. Performing a cranial dressing change with sterile gloves D. Keeping the head in a neutral position when turning the client Answer: B. Instructing the client to cough forcefully

Step-by-step solution

Analyze Action A

The student elevates the head of the bed \(30^{\circ}\). Elevating the head of the bed at an angle of \(30^{\circ}\) helps to decrease intracranial pressure (ICP) for post-craniotomy patients, improving blood flow and preventing complications. This action is appropriate and should not require intervention.

Analyze Action B

The student instructs the client to cough forcefully. Forceful coughing can cause an increase in ICP, which may lead to complications in a post-craniotomy patient. This action is inappropriate and would require nurse intervention.

Analyze Action C

The student is preparing to perform a cranial dressing change with sterile gloves. Performing a cranial dressing change with sterile gloves is a part of proper wound care after a craniotomy, helping to prevent infection. This action is appropriate and should not require intervention.

Analyze Action D

When turning the client, the student keeps the head in a neutral position. Maintaining a neutral head position is vital for preventing any undue stress on the surgical site and maintaining proper alignment of the cervical spine. This action is appropriate and should not require intervention.

Identify the action that requires intervention

From the analysis of each action, it is clear that Action B, where the student instructs the client to cough forcefully, is the one that requires nurse intervention, as it may lead to a risky increase in ICP. Therefore, the correct answer is B.