A client sustained a head injury when hit by a lead pipe two hours ago and is admitted for observation after the computerized tomography (CT) scan indicates that no spinal cord injury and no skull fractures are present.

When the client begins projectile vomiting, the nurse quickly turns the client's head to the side and administers ondansetron 4 mg IV as prescribed.

Reassessment indicates that the client's Glasgow coma score is 13 and the left pupil is dilated without reaction to light.

Which intervention(s) should the nurse implement? Select all that apply.

Place in lateral Trendelenburg position.

Schedule a repeat CT scan.

Insert a second large bore IV catheter.

Apply artificial tear drops to the left eye.

Repeat Glasgow coma assessment.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale

Placing a client with a head injury in the lateral Trendelenburg position is not recommended due to the risk of increasing intracranial pressure (ICP). This position can impede venous outflow from the brain, thereby exacerbating cerebral edema and ICP. Additionally, it can compromise the airway and lead to aspiration, especially in a client who is vomiting. Proper positioning, such as elevating the head of the bed to 30 degrees, is more appropriate to facilitate venous drainage and reduce ICP while protecting the airway. This choice is scientifically unsound and potentially harmful.

Choice B rationale

Scheduling a repeat CT scan is a critical intervention in this case. The client's condition has changed, evidenced by the onset of projectile vomiting and a dilated, non-reactive left pupil, both signs of potential increased ICP and possible brain herniation. A repeat CT scan will help identify any new or worsening intracranial pathology such as bleeding, swelling, or other changes that were not present initially. Timely imaging is essential for appropriate management and to guide further treatment decisions.

Choice C rationale

Inserting a second large bore IV catheter is vital for ensuring rapid access for fluids, medications, and possible blood products in the event of an acute deterioration. This is especially important in a neurologically unstable client. Having multiple IV access points allows for efficient administration of necessary treatments without delay, which can be crucial in managing worsening intracranial conditions and other emergent needs.

Choice D rationale

While applying artificial tear drops to the left eye might seem beneficial for preventing corneal dryness in a client who cannot blink, it does not address the acute neurological concerns indicated by the pupil changes and vomiting. This intervention is more supportive rather than urgent or diagnostic. The primary focus should be on identifying and managing the underlying cause of the client's deterioration, not on symptom management alone.

Choice E rationale

Repeating the Glasgow coma assessment is necessary to monitor any changes in the client's neurological status. Regular assessment helps track the progression or improvement of the client’s condition, guiding clinical decisions. The change in pupil response and vomiting suggests potential worsening, necessitating continuous and frequent reassessments. Prompt detection of deterioration can lead to quicker intervention and potentially better outcomes.

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Correct Answer is A

Explanation

Choice A rationale

A client with a positive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) requires a negative airflow room and airborne precautions. This is to prevent the spread of tuberculosis (TB), an infectious disease that can be transmitted through airborne particles. The use of a particulate respirator mask by healthcare personnel is essential in protecting themselves from inhaling infectious aerosols. Implementing these precautions is critical in controlling the spread of TB within healthcare settings and ensuring patient and staff safety.

Choice B rationale

A client with genital herpes simplex II lesions does not require a negative airflow room or airborne precautions. Herpes simplex virus (HSV) is primarily transmitted through direct contact with infected lesions or body fluids. Standard precautions, including contact precautions when dealing with lesions, are adequate to prevent the spread of HSV. Negative airflow rooms and airborne precautions are not necessary for managing this condition.

Choice C rationale

Scarlet fever, complicated with pneumonia, primarily requires standard and droplet precautions rather than airborne precautions. Scarlet fever is caused by group A Streptococcus, which is spread through respiratory droplets. While pneumonia can increase the severity of the infection, negative airflow rooms and particulate respirators are not typically required. Droplet precautions, such as wearing masks and maintaining distance, are sufficient to prevent transmission.

Choice D rationale

Scabies is a parasitic infestation that spreads through direct skin-to-skin contact or contact with contaminated items such as bedding and clothing. Negative airflow rooms and airborne precautions are not necessary for managing scabies. Standard and contact precautions, including wearing gloves and gowns and thoroughly cleaning and disinfecting contaminated items, are adequate to prevent the spread of the mites causing scabies. The use of a particulate respirator mask is not required.

A. Assisting with pushing efforts B. Administering bolus fluids C. Monitoring blood pressure D. Administering IV fluids E. Side positioning

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

Interventions	Support Epidural Anesthesia for Mother	Support Epidural Anesthesia for Fetus
Assisting with pushing efforts	✓
Administering bolus fluids	✓
Monitoring blood pressure	✓	✓
Administering IV fluids	✓
Side positioning	✓	✓

Assisting with pushing efforts:

Goal: Support Epidural Anesthesia for Mother
Reason: Epidural anesthesia can diminish the mother's ability to feel the urge to push during labor. Assisting with pushing efforts helps ensure effective delivery and supports the mother's ability to participate actively in the birthing process.

Administering bolus fluids:

Goal: Support Epidural Anesthesia for Mother
Reason: Administering bolus fluids can help prevent hypotension, a common side effect of epidural anesthesia. Ensuring adequate fluid volume maintains blood pressure and supports overall maternal hemodynamic stability.

Monitoring blood pressure:

Goal: Support Epidural Anesthesia for Mother and Fetus
Reason: Continuous monitoring of blood pressure is essential to detect and manage hypotension, ensuring both maternal and fetal well-being. It helps maintain adequate blood flow to the uterus and placenta, optimizing fetal perfusion.

Administering IV fluids:

Goal: Support Epidural Anesthesia for Mother
Reason: Administering IV fluids helps maintain hydration and blood pressure, counteracting the potential hypotensive effects of epidural anesthesia. It supports the mother's hemodynamic stability during labor.

Side positioning:

Goal: Support Epidural Anesthesia for Mother and Fetus
Reason: Side positioning optimizes uteroplacental blood flow and reduces the risk of aortocaval compression by the gravid uterus. It ensures better fetal perfusion and maternal comfort while receiving epidural anesthesia.

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Naxlex Comprehensive Predictor Exams

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A,B"},"D":{"answers":"A"},"E":{"answers":"A,B"}}

Explanation

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.

The mother of a child with cerebral palsy (CP) asks the nurse if her child's impaired movements will worsen as the child grows. Which response provides the best explanation?

The nurse is completing the admission assessment of a client with multiple sclerosis (MS). Which finding(s) should be reported to the healthcare provider immediately? Select all that apply.

While caring for a toddler receiving oxygen via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Arterial Blood Gas Laboratory Test