A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse’s best intervention for preventing injury?

Arrange for friends and family members to sit with the client

Restrain the client as ordered

Pad the side rails of the client’s bed

Administer opioids PRN as prescribed

Answer and Explanation

The Correct Answer is C

Reasoning:

Choice A reason: Arranging for friends and family to sit with the client may provide comfort but does not directly prevent injury from agitation. Family presence cannot ensure physical safety during sudden movements, whereas padding side rails directly reduces harm from agitation-related impacts in head injury.

Choice B reason: Restraining the client increases agitation and injury risk in head-injured patients, as it can exacerbate distress and cause pressure injuries. Non-restrictive measures like padding are safer, reducing harm from agitation without compromising autonomy or worsening neurological status in this high-risk population.

Choice C reason: Padding side rails is the best intervention to prevent injury in an agitated client with a head injury. Agitation increases the risk of hitting bed rails, causing bruises or fractures. Padding absorbs impact, ensuring safety without restricting movement, addressing the immediate physical risk effectively.

Choice D reason: Administering opioids PRN may reduce pain but not agitation in head injury. Opioids can depress respiration and consciousness, potentially masking neurological changes or worsening ICP, making them less safe than padding side rails to prevent physical injury from agitation-related movements.

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Correct Answer is D

Explanation

Reasoning:

Choice A reason: Encouraging increased oral intake is inappropriate for SIADH, as it exacerbates water retention caused by excessive ADH. This would worsen dilutional hyponatremia and fluid overload, potentially leading to severe complications like cerebral edema, making fluid restriction the preferred approach to manage this condition.

Choice B reason: Infusing IV fluids rapidly is contraindicated in SIADH, as it increases fluid overload. Excessive ADH already causes water retention, diluting serum sodium. Rapid IV fluid administration could worsen hyponatremia and lead to neurological complications, such as seizures, due to further dilution of electrolytes.

Choice C reason: Administering glucose-containing IV fluids is not appropriate for SIADH, as it adds to the fluid volume, worsening water retention and hyponatremia. Glucose fluids do not address the underlying ADH excess and may exacerbate dilutional effects, increasing the risk of cerebral edema or other complications.

Choice D reason: Restricting fluids is the appropriate intervention for SIADH, as excessive ADH causes water retention, leading to hyponatremia. Limiting fluid intake helps correct the dilutional effect, increasing serum sodium concentration and reducing the risk of complications like cerebral edema, aligning with the goal of restoring fluid balance.

A. Pale thick skin B. Moon face C. Weight loss D. Hypotension

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Pale thick skin is not a typical effect of long-term corticosteroid use. Corticosteroids cause skin thinning due to reduced collagen production, leading to fragile, atrophic skin prone to bruising. Thick skin is more associated with conditions like scleroderma, not the catabolic effects of corticosteroids on skin tissue.

Choice B reason: Moon face is a classic sign of long-term corticosteroid use, resulting from fat redistribution to the face due to glucocorticoid-induced lipolysis and lipogenesis. Excess cortisol promotes fat deposition in the face and trunk, creating a rounded facial appearance, a hallmark of Cushing syndrome or iatrogenic corticosteroid effects.

Choice C reason: Weight loss is not expected with long-term corticosteroid use. Corticosteroids increase appetite and promote fat redistribution, leading to weight gain, particularly in the trunk and face. Weight loss may occur in conditions like Addison’s disease, where cortisol is deficient, not in hypercortisolism states.

Choice D reason: Hypotension is not a common effect of corticosteroids. They can cause fluid retention and increased blood volume due to mineralocorticoid activity, potentially leading to hypertension. Hypotension is more associated with adrenal insufficiency, where cortisol and aldosterone deficiencies reduce vascular tone and fluid balance.

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A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse’s best intervention for preventing injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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