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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. While ensuring proper alignment is important, it does not address the existing skin breakdown and irritation.
B. Applying zinc oxide cream may not be appropriate as it can trap moisture, potentially worsening the skin condition around pin sites.
C. Padding the areas of skin breakdown with foam dressing is an appropriate intervention as it can provide cushioning, reduce friction, and protect the skin from further injury.
D. Loosening the halo device could compromise the stabilization it provides and may not effectively address skin integrity issues.

A. Hypocalcemia B. Hypercalcemia C. Hypokalemia D. Hyponatremia

Correct Answer is A

Explanation

A. Chvostek's sign, a facial muscle spasm upon tapping, is a clinical indicator of hypocalcemia, often caused by accidental removal or damage to the parathyroid glands during thyroid surgery.
B. Hypercalcemia does not typically cause a positive Chvostek’s sign.
C. Hypokalemia affects muscle and cardiac function but does not result in a positive Chvostek’s sign.
D. Hyponatremia does not produce Chvostek's sign, which is specific to hypocalcemia.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client with a halo device. The client has developed skin breakdown and irritation around the pin sites. Which intervention is most appropriate for the nurse to implement to prevent further skin complications?

Correct Answer is C

Explanation

A nurse is caring for a client who is postoperative following a subtotal thyroidectomy. The nurse assesses for the presence of Chvostek's sign to indicate which of the following electrolyte imbalances?

Correct Answer is A

Explanation

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