A client with a head injury has an arterial blood pressure of 108/54 mmHg and an intracranial pressure of 15 mmHg. Which action by the nurse is appropriate?

Document and continue to monitor the parameters.

Notify the health care provider about the assessments.

Decrease the client's IV infusion rate.

Check the client's pupillary response to light.

Answer and Explanation

The Correct Answer is B

A. Document and continue to monitor the parameters: While ongoing monitoring is important, the combination of hypotension and ICP of 15 mmHg may compromise cerebral perfusion. Immediate reporting is necessary rather than passive observation.

B. Notify the health care provider about the assessments: Hypotension in a client with a head injury can reduce cerebral perfusion pressure and worsen brain injury. ICP of 15 mmHg is at the upper limit of normal. Promptly notifying the provider ensures timely interventions to optimize perfusion and prevent secondary brain injury.

C. Decrease the client's IV infusion rate: Reducing IV fluids could exacerbate hypotension and further compromise cerebral perfusion. Volume support may be necessary to maintain adequate blood pressure in a head-injured client.

D. Check the client's pupillary response to light: Assessing pupillary response is part of neurologic monitoring, but it does not address the immediate concern of low blood pressure affecting cerebral perfusion. Action should focus on hemodynamic stability first.

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Correct Answer is A

Explanation

A. A client with a blunt chest trauma with some difficulty breathing: Blunt chest trauma with respiratory difficulty indicates pneumothorax or pulmonary contusion. These conditions can deteriorate rapidly if not treated immediately. Airway and breathing always take priority in emergency triage. Early management prevents respiratory failure and severe hypoxia.

B. A client with confusion: Confusion suggests neurological or metabolic issues, but there is no indication of airway or breathing compromise. The condition requires prompt evaluation but does not present the same immediate danger as respiratory distress. The client is more stable and can be safely reassessed once life-threatening issues are addressed.

C. A client with a sore neck who was immobilized in the field on a backboard with a cervical collar: The client may have a spinal injury, but immobilization already provides protection from further harm. There is no evidence of airway or breathing instability that would elevate the urgency. This allows the client to wait safely while higher-priority conditions are treated.

D. A client with a possible fractured tibia with adequate pedal pulses: A tibial fracture is not life-threatening when distal pulses are present, indicating that circulation to the limb is intact. The client is stable and can safely wait while emergent issues are managed first. Orthopedic injuries without vascular compromise pose minimal immediate risk.

A. Perform a halo test B. Instruct the client to blow his nose and check the nares for inflammation. C. Obtain a specimen of the fluid for culture and sensitivity. D. Check the nasal drainage for glucose.

Correct Answer is A

Explanation

A. Perform a halo test: Clear nasal drainage in a client with periorbital ecchymosis may indicate cerebrospinal fluid (CSF) leakage. The halo or ring test helps differentiate CSF from normal nasal secretions, which is critical for detecting a basilar skull fracture. Early identification guides further neurologic assessment and prevents complications.

B. Instruct the client to blow his nose and check the nares for inflammation: Blowing the nose can increase intracranial pressure and worsen CSF leakage. Assessing for inflammation does not confirm CSF presence and may be harmful in suspected skull fractures.

C. Obtain a specimen of the fluid for culture and sensitivity: Culturing the fluid is unnecessary initially and may delay urgent assessment. Identifying CSF leakage takes priority to prevent infection and guide immediate care.

D. Check the nasal drainage for glucose: Glucose testing can suggest CSF, but the halo test provides a more rapid and reliable bedside assessment. Confirming CSF leakage quickly is essential for early intervention.

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A client with a head injury has an arterial blood pressure of 108/54 mmHg and an intracranial pressure of 15 mmHg. Which action by the nurse is appropriate?

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Naxlex Comprehensive Predictor Exams

Which client should the nurse prioritize as needing emergent treatment assuming no other injuries are present except the ones outlined below?

Correct Answer is A

Explanation

The nurse notes that a client with a head injury and periorbital ecchymosis has clear nasal drainage. Which nursing action is most appropriate upon this finding?

Correct Answer is A

Explanation

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