A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?
Administer opioids.
Apply restraints.
Reduce stimuli.
Blacken the room.
The Correct Answer is C
An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure. The nurse can reduce stimuli by minimizing noise and light in the client's environment and limiting the number of visitors.
Administering opioids, applying restraints, and blackening the room are not appropriate nursing actions for this situation. Administering opioids can cause respiratory depression and is not recommended for clients with increased intracranial pressure. Applying restraints can increase agitation and is not recommended for clients who are restless. Blackening the room can disorient the client and is not recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Having the client lie prone several times each day is an appropriate nursing intervention for a client who is 2 days postoperative following an above-the-knee amputation. Lying prone can help prevent hip flexion contractures, which can occur after an above-the-knee amputation².
a. Elevating the foot of the bed is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
b. Encouraging sitting up as much as possible is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
c. Elevating the stump on a pillow is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.
Correct Answer is B
Explanation
Boutonniere deformity is an expected finding for a client who has rheumatoid arthritis. It is a type of hand deformity that can occur in people with rheumatoid arthritis. It is characterized by a bent middle finger joint and a hyperextended fingertip.
Tophi, osteoma, and Heberden's nodules are not expected findings for a client who has rheumatoid arthritis. Tophi are deposits of uric acid crystals that can occur in people with gout. Osteoma is a benign bone tumour. Heberden's nodules are bony growths that can occur in people with osteoarthritis.
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