A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Intracranial pressure

Respiratory status

Temperature

Serum electrolytes

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is D

Explanation

A. The client can follow simple motor commands: A GCS score of 5 for the best motor response indicates that the client can localize pain but cannot follow simple motor commands. A score of 6 or higher is required to demonstrate following commands.

B. The client is unable to make vocal sound: A GCS score of 5 for the best verbal response indicates incomprehensible sounds or no verbal response. It does not specifically indicate the client's ability to vocalize or make sounds.

C. The client opens his eyes when spoken to: A GCS score of 3 for eye opening indicates no eye opening even to painful stimuli. It does not suggest that the client opens his eyes when spoken to.

D. The client is unconscious: A GCS score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response indicates severe neurological impairment, with the client being unresponsive to stimuli and unable to follow commands. Therefore, the appropriate conclusion is that the client is unconscious.

A. Place the client with the head reclined back to facilitate swallowing. B. Place food in the affected side of the mouth. C. Encourage the client to take small bites. D. Encourage brief exercise before meals to promote appetite.

Correct Answer is C

Explanation

A. Placing the client with the head reclined back can increase the risk of aspiration and is not recommended.
B. Placing food in the affected side of the mouth could lead to choking, as the client may have reduced sensation or control on that side.
C. Encouraging the client to take small bites can help prevent choking and make swallowing easier.
D. While exercise might promote appetite, it is not directly related to feeding safety and should be discussed separately from swallowing instructions.

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A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

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