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.

Answer and Explanation

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^].

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Correct Answer is ["0.2"]

Explanation

- Step 1: Identify the required dose in milligrams (mg). The nurse is scheduled to administer 2 mg of morphine sulfate.

- Step 2: Identify the concentration of the available solution. The available solution contains 10 mg of morphine sulfate per 1 mL.

- Step 3: Calculate the volume of solution needed to deliver the required dose. We can set up a proportion to solve for this:

- 10 mg is to 1 mL as 2 mg is to X mL.

- In other words, 10 mg : 1 mL = 2 mg : X mL.

- Step 4: Solve for X using cross-multiplication and division:

- Cross-multiplication gives us: 10 mg × X mL = 2 mg × 1 mL.

- Simplifying this gives us: 10X = 2.

- Dividing both sides by 10 gives us: X = 2 ÷ 10.

- Calculating the division gives us: X = 0.2.

So, the nurse should administer 0.2 mL of the morphine sulfate solution per dose.

A. Place the client in a sitting position B. Examine the client for areas of skin breakdown C. Check the client's bladder for distention D. Check the client for a fecal impaction

Correct Answer is A

Explanation

Choice A reason:Placing the client in a sitting position helps to lower blood pressure by promoting venous return and is the first action to take in cases of autonomic dysreflexia²³.

Choice B reason:While examining for skin breakdown is important, it is not the first action to take when autonomic dysreflexia is suspected.

Choice C reason:Checking the bladder for distention is a critical step, but it should be done after positioning the client to address immediate blood pressure concerns.

Choice D reason:Checking for fecal impaction is also important but follows the initial step of positioning the client to manage blood pressure.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a 2 mg IV bolus of morphine sulfate. Morphine sulfate is available in a concentration of 10 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["0.2"]

Explanation

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

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