A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?
Place a cool cloth on the forehead.
Elevate the head of the bed 30 degrees.
Administer morphine 2 mg IV.
Prepare for a lumbar puncture.
The Correct Answer is B
Choice A reason:Placing a cool cloth on the forehead may provide comfort but does not address intracranial pressure, which could be causing the headache[^10^].
Choice B reason:Elevating the head of the bed 30 degrees helps to decrease intracranial pressure and can alleviate headache symptoms associated with a closed head injury[^10^].
Choice C reason:Administering morphine for pain relief should be done with caution, as it can depress respiration and mask changes in the level of consciousness, which are important indicators of neurological status[^10^].
Choice D reason:A lumbar puncture is contraindicated in the presence of increased intracranial pressure due to the risk of brain herniation[^10^].
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:Increased serum amylase is a common finding in acute pancreatitis as it is released from the inflamed pancreas[^10^].
Choice B reason:A decreased WBC count is not typically associated with acute pancreatitis; an increased count may indicate infection or inflammation.
Choice C reason:Serum calcium is often decreased in acute pancreatitis due to fat saponification and hypoalbuminemia.
Choice D reason:Decreased serum lipase would not be expected; increased levels are indicative of acute pancreatitis, similar to amylase[^10^].
Correct Answer is C
Explanation
Choice A reason:Rescheduling the scan is not necessary unless there are other contraindications or scheduling conflicts.
Choice B reason:Sending a suction catheter is a precautionary measure, but it does not address the management of the feeding tube during the scan.
Choice C reason:Shutting off the feeding 30-60 minutes before the scan is a standard practice to reduce the risk of aspiration and to ensure that the stomach contents do not interfere with the imaging.
Choice D reason:Connecting the feeding tube to continuous suction is not typically required unless there is a specific concern for aspiration or gastric content management during the scan.
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