A nurse in the emergency department is caring for a female client brought to the ER by family for fatigue.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Rationale:

Potential Condition: Hypothyroidism - The client exhibits signs consistent with hypothyroidism, including fatigue, weight gain, decreased appetite, hair loss, constipation, and intolerance to cold. The laboratory results show low serum T3 and T4 levels, confirming this diagnosis.
Actions to Take:
- Request a prescription for Thyroid hormone replacement: This is crucial for managing hypothyroidism and restoring normal metabolic function.
- Administer supplemental oxygen: Given the client’s low oxygen saturation (92%), this intervention is essential to ensure adequate oxygen delivery and prevent further complications.
Parameters to Monitor:
- Bowel function: Monitoring bowel habits is important since constipation is a common symptom of hypothyroidism, and managing this aspect can improve the patient's overall comfort and health.
- Oxygen saturation: Continuous assessment of oxygen levels is necessary to address the patient's respiratory needs and detect any further deterioration.

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Correct Answer is C

Explanation

A. While pain level assessment is important, it is not the priority immediately after a significant brain injury where neurological changes may occur.
B. Wound site assessment is also essential but does not take precedence over neurological assessment in this context.
C. A neurological assessment is the priority to identify any changes in the client's condition that may indicate complications such as increased intracranial pressure, which can occur after brain surgery.
D. Respiratory status assessment is important but is usually addressed through monitoring and interventions related to neurological function, as brain injuries can affect respiratory drive and function.

A. Place the client in a supine position. B. Instruct client to pull self up in bed C. Use log rolling to reposition the client. D. Assist client to sit with legs dangling

Correct Answer is C

Explanation

A. The supine position can increase ICP and is not recommended for clients with elevated ICP.
B. Instructing the client to pull themselves up may increase ICP due to straining.
C. Log rolling helps maintain spinal alignment and minimizes abrupt head movement, which is essential in managing ICP.
D. Sitting with legs dangling may cause a sudden shift in intracranial pressure and is not advised for these clients.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client 4 hours following surgical repair of a penetrating brain injury. Which of the following assessments should be the nurse's priority?

Correct Answer is C

Explanation

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following positioning techniques should the nurse implement?

Correct Answer is C

Explanation

A nurse is caring for a client who is demonstrating signs of increasing intracranial pressure (ICP). The nurse recognizes that which nursing actions are indicated to decrease ICP?

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? Select all that apply.

The nurse is providing teaching on the miotic medication the client has been prescribed for glaucoma. The client asks the nurse about the purpose of the medication. Which response should the nurse provide to the client?

The nurse is caring for a client who sustained a head injury in a motor vehicle accident and is diagnosed with a subdural hematoma and increased intracranial pressure. Which nursing intervention is appropriate for this client?

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