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A nurse is caring for a client on a medical-surgical unit

 

Exhibits

 

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

as evidenced by the client's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Option 1: Intracranial hemorrhage: The client’s recent fall, worsening headache, unilateral pupil dilation, right-sided weakness, and decreasing Glasgow Coma Scale (GCS) indicate a potential neurological injury, which is concerning for intracranial hemorrhage.

Option 2: Glasgow Coma Scale: The client's GCS has progressively declined (from 15 to 13), indicating a decrease in neurological function, which is critical in assessing intracranial pressure and risk for hemorrhage.


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Related Questions

Correct Answer is C

Explanation

A. Checking for fecal impaction can help relieve the cause of autonomic dysreflexia but should be done after positioning the client.

B. Skin breakdown can trigger autonomic dysreflexia, but the immediate priority is to lower blood pressure by sitting the client up.

C. Placing the client in a sitting position helps lower blood pressure, which is the immediate concern in autonomic dysreflexia.

D. Checking for bladder distention is essential to find the trigger, but positioning comes first to manage the acute blood pressure elevation.

Correct Answer is ["A","C","E","F"]

Explanation

A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.

B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.

C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.

D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.

E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.

F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.

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