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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Documenting the wound measurements with tunneling is important for tracking the wound's progression and planning appropriate interventions. Accurate documentation helps in assessing the effectiveness of the treatment plan.

Choice B rationale

Cleansing the wound and discontinuing the VAC system is necessary when foul, purulent drainage is observed. This action helps to prevent further infection and allows the healthcare provider to reassess the wound care approach.

Choice D rationale

Consulting the wound care specialist to evaluate the wound is essential for expert advice on managing complex wounds. Specialists can provide tailored recommendations to promote wound healing and prevent complications.

Choice C rationale

Increasing the wound VAC suction to eliminate the drainage is not appropriate as it may worsen the infection or damage the surrounding tissues. Proper wound care protocols should be followed to ensure safe and effective treatment.

Choice E rationale

Reapplying the VAC system after irrigating away drainage is not advisable if there is evidence of infection. The wound should be thoroughly assessed, and appropriate measures should be taken to address the underlying infection.

A. Calcium carbonate. B. Acetaminophen. C. Hydrochlorothiazide. D. Lithium carbonate.

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Calcium carbonate is a common medication used to manage low calcium levels, but in clients with hyperparathyroidism, it can exacerbate hypercalcemia, leading to dangerous levels of calcium in the blood. Hyperparathyroidism already causes increased calcium release from bones, increased absorption from the intestines, and decreased excretion by the kidneys, so adding calcium carbonate can worsen these effects, potentially leading to complications like kidney stones, bone pain, and cardiovascular issues. Careful monitoring and possible dose adjustments or discontinuation might be necessary.

Choice B rationale

Acetaminophen is an analgesic and antipyretic commonly used for pain relief and fever reduction. It is metabolized primarily in the liver and does not significantly impact calcium levels or parathyroid hormone function. Therefore, it does not pose an immediate concern for clients with hyperparathyroidism and can typically be used safely without requiring further discussion with the healthcare provider unless there are other contraindications or hepatic issues in the client's medical history.

Choice C rationale

Hydrochlorothiazide is a thiazide diuretic often used to manage hypertension and edema. It reduces urine calcium excretion, which can lead to increased serum calcium levels, exacerbating hypercalcemia in clients with hyperparathyroidism. Thiazide diuretics promote calcium reabsorption in the distal convoluted tubules of the kidneys, potentially worsening the hypercalcemia caused by hyperparathyroidism. Therefore, the use of hydrochlorothiazide should be carefully evaluated and potentially avoided in these clients.

Choice D rationale

Lithium carbonate is used to treat bipolar disorder and can affect parathyroid function, leading to increased parathyroid hormone (PTH) levels and hypercalcemia. Lithium can alter the set point of the calcium-PTH feedback loop, leading to increased release of PTH, even at normal calcium levels. This can result in worsening hyperparathyroidism and hypercalcemia, making it a medication that requires careful consideration and monitoring in affected clients.

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Naxlex Comprehensive Predictor Exams

When changing the client's dressing for a vacuum-assisted closure (VAC) wound therapy system, the nurse observes foul, purulent drainage. Which intervention(s) should the nurse implement? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

The nurse is managing the care for a client with hyperparathyroidism and is reviewing the client's list of prescribed and over-the-counter medications. Which medication(s) on the client's current medication record should the nurse discuss further with the healthcare provider? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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A client with hemorrhoids asks for information about a high fiber diet. Which breakfast menu item(s) should the nurse suggest? Select all that apply.

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A nurse is admitting a client from the postanesthesia care unit (PACU) to the postoperative surgical care unit. Which prescription should the nurse implement first?

The nurse is caring for a client who has a history of experiencing delusions. The client describes singing in a concert in the afternoon for thousands of people. Which action should the nurse take?

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