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 D

Explanation

A. Exophthalmos is typically associated with hyperthyroidism (specifically Graves' disease) rather than hypothyroidism.
B. Diaphoresis (excessive sweating) is also more common in hyperthyroid states, not hypothyroidism.
C. Palpitations are indicative of an increased metabolic rate, which is common in hyperthyroidism; therefore, they would not be expected in a client with hypothyroidism.
D. Lethargy is a classic symptom of hypothyroidism due to decreased metabolism, leading to fatigue and reduced energy levels, making it the expected finding.

A. Note the time of day the test was done. B. Apply normal saline drops. C. Instruct the client to sleep with the head of the bed flat. D. Contact the primary health care provider.

Correct Answer is D

Explanation

A. While noting the time of day is important for documentation, it does not address the immediate concern of elevated intraocular pressure (IOP).
B. Applying normal saline drops is not indicated in the immediate management of elevated IOP in glaucoma; it does not directly affect IOP levels.
C. Instructing the client to sleep with the head of the bed flat is not advisable, as elevated head positions may help decrease IOP.
D. An IOP of 23 mm Hg is above the normal range (10-21 mm Hg) and indicates potential glaucoma. Therefore, contacting the primary health care provider for further evaluation and treatment is the most appropriate initial action.

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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 assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

Correct Answer is D

Explanation

A nurse is performing a tonometry test on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure (IOP) value of 23 mm Hg. What should the nurse's initial action be?

Correct Answer is D

Explanation

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