A nurse is caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder.

Exhibits

Complete the following sentence by using the list of options.

The nurse should first address the client's

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followed by the client's

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A. Place suction equipment at the client's bedside: Impairment of cranial nerves IX and X can lead to difficulty swallowing and impaired gag reflex, increasing the risk of aspiration and airway obstruction. Therefore, having suction equipment readily available is essential to maintain a patent airway and manage secretions effectively.

B. Provide range-of-motion exercises to the client's neck and shoulders: While range-of-motion exercises may be beneficial for preventing muscle stiffness and contractures, they are not directly related to the client's risk of airway compromise or aspiration.

C. Apply an eye patch to the client's right eye: Acoustic neuroma typically affects cranial nerves VII and VIII, leading to symptoms such as hearing loss and facial weakness. Applying an eye patch to the client's right eye is not necessary for cranial nerve IX and X impairment unless there are specific ocular symptoms.

D. Avoid the use of warm water to wash the client's face: Warm water may be used to wash the client's face safely and is not contraindicated specifically for a client with impairment of cranial nerves IX and X. However, precautions should be taken to ensure that water does not enter the airway if the client has difficulty swallowing or impaired gag reflex.

A. Intracranial pressure: Monitoring intracranial pressure is important in clients with a history of subdural hematoma, but immediate assessment of respiratory status takes precedence in the immediate postoperative period to ensure adequate oxygenation and ventilation.

B. Respiratory status: Following evacuation of a subdural hematoma, the client may be at risk for respiratory compromise due to factors such as altered consciousness, impaired airway reflexes, or postoperative complications. Assessing respiratory rate, depth, oxygen saturation, and presence of respiratory distress is essential for early detection and intervention.

C. Temperature: Monitoring temperature is important for detecting signs of infection or systemic complications, but it is not the priority assessment immediately following evacuation of a subdural hematoma.

D. Serum electrolytes: While monitoring serum electrolytes is important for overall assessment and management of the client's condition, it is not the priority assessment in the immediate postoperative period following evacuation of a subdural hematoma.