The nurse establishes a diagnosis of Ineffective Tissue Perfusion: Cerebral for a client with increased intracranial pressure (ICP). Which of the following interventions would not be included in the client's plan of care?
A. Provide a quiet environment, limiting noxious stimuli.
B. Assess for bladder distention and bowel constipation.
C. Preoxygenate mechanically ventilated client with 100% oxygen before suctioning
D. Cluster nursing care
Answer:D
The nurse establishes a diagnosis of Ineffective Tissue Perfusion: Cerebral for a client with increased intracranial pressure (ICP). Which of the following interventions would not be included in the client's plan of care?
A. Provide a quiet environment, limiting noxious stimuli. B. Assess for bladder distention and bowel constipation. C. Preoxygenate mechanically ventilated client with 100% oxygen before suctioning D. Cluster nursing care