A client sustained a head injury when hit by 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.

Insert a second large bore IV catheter.

Schedule a repeat CT scan.

Apply artificial tear drops to left eye.

Place in lateral Trendelenburg position.

Repeat Glasgow coma assessment.

Answer and Explanation

Correct Answer : B,C,E

A. Insert a second large bore IV catheter: This may be necessary in a trauma setting if volume resuscitation is needed, but there is no indication of hemodynamic instability or bleeding in this scenario. It is not the most immediate or essential response to new neurologic findings.

B. Schedule a repeat CT scan: A dilated, non-reactive pupil and change in neurologic status may indicate increased intracranial pressure or new bleeding. A repeat CT scan is critical to evaluate for worsening brain injury or cerebral herniation.

C. Apply artificial tear drops to left eye: A non-reactive pupil suggests cranial nerve involvement, possibly impairing the eye's ability to blink. To protect the cornea from drying and ulceration, artificial tears or eye protection is appropriate.

D. Place in lateral Trendelenburg position: Trendelenburg position is contraindicated in clients with suspected increased intracranial pressure, as it may worsen cerebral edema. The head should be elevated, not lowered.

E. Repeat Glasgow coma assessment: Frequent reassessment of neurologic status using the Glasgow Coma Scale helps detect early signs of deterioration and guides the urgency of interventions such as imaging or surgical evaluation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A. Assess characteristics of pain: Abdominal pain in a client on heparin may indicate gastrointestinal bleeding or other complications. Assessing the pain's onset, location, intensity, and nature is crucial for determining severity and guiding further intervention.

B. Monitor stools for presence of blood: The presence of tarry, black stools suggests upper gastrointestinal bleeding. Monitoring stool characteristics helps determine the extent and progression of bleeding, which may be related to anticoagulation therapy.

C. Auscultate bowel sounds in all quadrants: While part of a routine abdominal exam, listening to bowel sounds does not directly help in evaluating active bleeding or guiding immediate response to possible anticoagulant-induced hemorrhage.

D. Review last partial thromboplastin time (PTT) results: Reviewing the PTT is essential to evaluate the effectiveness and safety of heparin therapy. A prolonged PTT can increase bleeding risk and may require adjusting or holding the infusion.

E. Prepare to administer warfarin: Warfarin is not appropriate in the acute setting of suspected heparin-induced bleeding. It is introduced only after stabilization and overlap with heparin under careful monitoring, not during active bleeding symptoms.

A. Relax and reduce the amount of effort to solve the problem. B. Focus on small achievable tasks, not taxing problems. C. Concentrate on and ventilate emotions when distressed. D. Analyze past hurts and resentments to identify the source.

Correct Answer is B

Explanation

A. Relax and reduce the amount of effort to solve the problem: Advising the client to reduce effort may encourage avoidance, which can reinforce anxiety. Generalized anxiety disorder is better managed through structured, goal-directed strategies rather than passive disengagement.

B. Focus on small achievable tasks, not taxing problems: This promotes a sense of control and success, helping reduce overwhelming feelings common in anxiety. Breaking tasks into manageable steps can improve concentration and lower stress levels in daily functioning.

C. Concentrate on and ventilate emotions when distressed: While emotional expression can be helpful, excessive focus on emotions without problem-solving may intensify anxiety. It is more effective to combine emotional awareness with practical coping skills.

D. Analyze past hurts and resentments to identify the source: Deep emotional analysis is more appropriate in long-term psychotherapy than acute anxiety management. This strategy may be too introspective and overwhelming for someone struggling with current functional issues.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with deep vein thrombosis (DVT) is receiving a continuous heparin IV infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

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

Explanation

A client with generalized anxiety disorder does not want to communicate with friends, smokes 2 to 3 packages of cigarettes a day, and describes difficulty concentrating at work. Which coping strategy should the nurse include in the plan of care?

Correct Answer is B

Explanation

Click to indicate which interventions the nurse would include in the plan of care to support the expected outcomes of adequate epidural anesthesia on the mother and the fetus. Each column must have a least one response selected.

A postoperative client returns to the nursing unit following a ureterolithotomy via a flank incision. Which potential problem has the highest priority when planning nursing care for this client?

A female client presents to the clinic with a fever and sore throat as well as a rash on the hands, palms, and the soles of the feet. The client reports having intercourse once with a new partner approximately 8 weeks ago. Which condition should the nurse suspect?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.)

After a scheduled downtime, the computer documentation system fails to restart. Which action should the nurse take first?

The nurse is planning discharge instructions for a client with type 2 diabetes mellitus who will be starting exenatide. Which information should be included in the discharge instructions?