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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. During waking hours for 2 to 3 months after the injury: Wearing the garment only while awake provides insufficient pressure to control hypertrophic scarring. These garments require near-continuous wear for many months to achieve adequate collagen remodeling.

B. 4 to 6 hours a day for 6 months: This amount of daily use is far too limited to influence scar tissue formation. Pressure therapy must be applied almost continuously to keep collagen fibers flattened and prevent thick, raised scars.

C. Only at night while sleeping for a year after the injury: Night-only wear does not maintain the necessary constant pressure needed for optimal scar management. Scar tissue forms throughout the day, and removal for long hours reduces therapeutic effect.

D. Continuously: Elastic pressure garments are typically worn 23 hours per day for many months to control hypertrophic scarring. Continuous pressure supports proper collagen alignment and reduces scar thickness.

A. The client denies nausea or anorexia. B. The client's bilirubin level decreases. C. The client is alert and oriented. D. The client has at least one stool daily.

Correct Answer is C

Explanation

A. The client denies nausea or anorexia: While improved appetite is beneficial, it does not directly indicate that lactulose is effective. Lactulose is primarily used to reduce ammonia levels and prevent hepatic encephalopathy. Symptom relief alone does not confirm therapeutic effect.

B. The client's bilirubin level decreases: Lactulose does not directly affect bilirubin levels. Bilirubin reflects liver excretory function, not the medication’s action on ammonia. Changes in bilirubin are not a reliable measure of lactulose effectiveness.

C. The client is alert and oriented: Lactulose reduces blood ammonia by promoting its excretion via the gastrointestinal tract. Improved mental status, such as being alert and oriented, indicates effective reduction of ammonia and prevention of hepatic encephalopathy.

D. The client has at least one stool daily: While increased bowel movements are expected with lactulose, the frequency alone does not confirm that ammonia levels are adequately reduced. Stool output is a mechanism, not the ultimate therapeutic outcome.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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