A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

Reassess the client every 2 hours.

Implement seizure precautions.

Perform a Mini-Mental State Exam (MMSE).

Elevate head of bed to high Fowler's.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Reassess the client every 2 hours: The client is currently stable with intact neurological function, but head injuries can deteriorate rapidly. Regular reassessment every 2 hours allows early detection of changes in mental status, motor function, or vital signs, which is essential for timely intervention.

B. Implement seizure precautions: Seizure precautions are indicated if the client shows signs of seizure activity or has a history of post-traumatic seizures. Since the client is alert and exhibits normal neurological function, immediate seizure precautions are not the first priority.

C. Perform a Mini-Mental State Exam (MMSE): While an MMSE can provide a baseline cognitive assessment, it is not necessary as the next immediate action in a stable, alert client. Routine neurological monitoring takes priority over formal cognitive testing.

D. Elevate head of bed to high Fowler’s: Elevating the head of the bed can affect intracranial pressure. For head-injured clients, the head is typically elevated to 30 degrees, not high Fowler’s, to optimize cerebral perfusion while minimizing ICP. This intervention is not the immediate next step for a neurologically stable client.

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Correct Answer is A

Explanation

Rationale:
A. Neurologically stable without indications of an increased ICP: A GCS score of 14 indicates that the client is alert and responding appropriately, with only minimal changes in neurological function. Stability of this score over several hours suggests that intracranial pressure is being adequately controlled and that cerebral perfusion is maintained.

B. Risk for irreversible cerebral damage related to increased ICP: A consistent GCS of 14 does not reflect worsening neurological status. Irreversible cerebral damage is associated with persistently low or deteriorating GCS scores, generally below 8, in severe brain injury.

C. Rehabilitative prognosis is an expected full recovery: While a GCS of 14 reflects a mild injury and positive neurological function, it does not guarantee complete recovery. Long-term prognosis depends on additional factors such as the type and location of the brain injury.

D. Insertion of an ICP monitoring device is necessary: ICP monitoring is typically indicated when a client’s GCS is ≤8 or there is evidence of worsening intracranial pressure. With a stable score of 14, invasive monitoring is not immediately required unless new neurological changes occur.

A. Orient the client to her surroundings. B. Allow husband to stay at bedside. C. Implement seizure precautions. D. Assess for drainage from ears or nose.

Correct Answer is D

Explanation

Rationale:
A. Orient the client to her surroundings: While orientation is helpful for confusion, the client’s restlessness and confusion could indicate increasing intracranial pressure or cerebral bleeding, which require immediate physical assessment rather than reassurance.

B. Allow husband to stay at bedside: Allowing the husband to remain can provide emotional support, but this is not the priority when assessing for potentially life-threatening neurological changes. Emotional comfort is secondary to detecting and managing complications of head trauma.

C. Implement seizure precautions: Seizure precautions are appropriate for clients with head injuries but should follow a focused neurological assessment. Detecting cerebrospinal fluid (CSF) leakage or signs of skull fracture takes precedence because it indicates a severe brain injury requiring urgent intervention.

D. Assess for drainage from ears or nose: Clear or bloody drainage may indicate CSF leakage due to a basilar skull fracture. Identifying this finding early is critical to prevent infection, monitor for increased intracranial pressure, and guide emergent management, making this the most important immediate nursing action.

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A client who sustained a head injury is alert and oriented to person, place, time, and situation, moves all extremities on command, has equal muscle strength bilaterally, and pupils are reactive to light. Which action should the nurse implement next?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Correct Answer is D

Explanation

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