A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless.
Which of the following assessments should the nurse perform first?
Motor responses.
Blood glucose.
Urinary output.
Blood pressure.
The Correct Answer is D
A change in behavior such as agitation and restlessness in a client with a traumatic brain injury can be a sign of increased intracranial pressure.
The nurse should first assess the client’s blood pressure as an increase in blood pressure can be an indicator of increased intracranial pressure.
Motor responses are not the first assessment that should be performed.
Blood glucose is not the first assessment that should be performed.
Urinary output is not the first assessment that should be performed.
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Related Questions
Correct Answer is D
Explanation
The client’s ABG results show a pH of 7.24, which is below the normal range of 7.35-7.45 and indicates acidosis.
The PaCO2 is within the normal range of 35-45 mm Hg, indicating that the acidosis is not caused by a respiratory issue.
The HCO3 level is 18 mEq/L, which is below the normal range of 22-28 mEq/L and indicates a primary metabolic cause for acidosis.
Respiratory acidosis is not indicated by the ABG results as the PaCO2 is within the normal range.
B) Metabolic alkalosis is not indicated by the ABG results as the pH and HCO3 levels are below their respective normal ranges.
C) Respiratory alkalosis is not indicated by the ABG results as the pH is below the normal range and the PaCO2 is within the normal range.
Correct Answer is B
Explanation
“Furosemide.” The nurse should anticipate administering furosemide because the client’s symptoms of bounding peripheral pulses, hypertension, and distended jugular veins may indicate fluid overload.
Furosemide is a diuretic medication that can help reduce fluid overload by increasing urine output.
Choice A is incorrect because diphenhydramine is an antihistamine medication that is not used to treat fluid overload.
Choice C is incorrect because acetaminophen is a pain reliever and fever reducer that is not used to treat fluid overload.
Choice D is incorrect because pantoprazole is a proton pump inhibitor that is used to treat acid reflux and stomach ulcers, not fluid overload.
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