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 C

Explanation

Reasoning:

Choice A reason: Detecting infection via fever and tachycardia is important in sickle cell anemia, but auscultation of lungs and heart is not primarily for these signs. Fever is assessed by temperature, and tachycardia by pulse, not stethoscope. Auscultation focuses on organ-specific complications like respiratory or cardiac issues, not systemic signs.

Choice B reason: Dehydration can trigger sickle cell crises, but auscultation of lungs and heart does not directly assess hydration status. Fluid status is evaluated through vital signs, skin turgor, or urine output, not heart or lung sounds, making this response less accurate for the purpose of auscultation.

Choice C reason: Auscultating lungs and heart in sickle cell anemia detects abnormal sounds indicating acute respiratory complications, like acute chest syndrome, or heart failure from chronic anemia or vaso-occlusion. Crackles, wheezes, or murmurs suggest these complications, making this the most accurate explanation for the child’s question.

Choice D reason: Motor strength and stroke-related signs are assessed through neurological exams, not lung or heart auscultation. While stroke is a risk in sickle cell anemia due to vaso-occlusion, auscultation targets cardiopulmonary complications, not motor or neurological deficits, making this response inappropriate.

A. Third-spacing and hyperthermia B. Bradycardia and hypertension C. Tachycardia and agitation D. Respiratory distress and projectile vomiting

Correct Answer is B

Explanation

Reasoning:

Choice A reason: Third-spacing and hyperthermia are not typical of autonomic dysreflexia, a condition in spinal cord injury causing sympathetic overactivity. Third-spacing occurs in fluid shifts like edema, and hyperthermia suggests infection, not the autonomic response to stimuli like bladder distension triggering dysreflexia.

Choice B reason: Autonomic dysreflexia, common in spinal cord injuries above T6, causes bradycardia and hypertension. Noxious stimuli (e.g., bladder distension) trigger sympathetic overactivity, raising blood pressure, while baroreceptors stimulate vagal response, slowing heart rate, making these classic manifestations of this life-threatening condition.

Choice C reason: Tachycardia and agitation may occur in other conditions but are not primary in autonomic dysreflexia. Hypertension triggers a compensatory bradycardia, not tachycardia, and while agitation may accompany distress, the hallmark is the cardiovascular response, making this less accurate.

Choice D reason: Respiratory distress and projectile vomiting are not primary manifestations of autonomic dysreflexia. While severe hypertension may cause nausea, the classic signs are bradycardia and hypertension due to sympathetic overactivity from stimuli below the spinal injury, not respiratory or vomiting issues.

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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

A nurse is doing a physical examination of a child with sickle cell anemia. When the child asks why the nurse auscultates the lungs and heart, what would be the best response by the nurse?

Correct Answer is C

Explanation

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Correct Answer is B

Explanation

A client is brought to the emergency department with symptoms of a cerebrovascular accident (CVA). The nurse would anticipate which diagnostic evaluation to be completed prior to initiation of treatment?

A client’s family member asks the nurse why disseminated intravascular coagulation (DIC) occurs. Which statement by the nurse correctly explains the cause of DIC?

The nurse observes a co-worker who always seems to be eating a cup of ice. The nurse encourages the co-worker to have an examination and diagnostic workup with the health care provider. What type of anemia is the nurse concerned that the co-worker may have?

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Which endocrine disorder causes the client to have dilutional hyponatremia?

Which of the following assessments should the nurse perform to determine the development of peptic ulcers when caring for a client with Cushing's syndrome?

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