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?
Pain level assessment.
Wound site assessment.
Neurological assessment.
Respiratory status assessment.
The Correct Answer is C
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Miotic medications work by constricting the pupil, which opens the trabecular meshwork and facilitates the drainage of aqueous humor, thus lowering intraocular pressure in clients with glaucoma.
B. Miotics do not dilate the pupil; they constrict it. Dilation would actually increase intraocular pressure, which is not therapeutic in glaucoma.
C. While these medications do affect eye muscles, they do not specifically prevent blurred vision; their primary effect is on eye pressure.
D. Miotics do not block nerve responses; they work by direct action on the eye muscles to promote fluid drainage and reduce pressure.
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.
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