A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash. For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?

The client has a delayed response to verbal commands.

The client has ecchymosis around the eyes.

The client is unable to remember details of the motor-vehicle crash.

The client reports ringing in the ears.

Answer and Explanation

The Correct Answer is A

Choice A Reason:

The client has a delayed response to verbal commands. This finding can indicate increased intracranial pressure. Changes in responsiveness, such as delayed responses to verbal commands or other stimuli, can be indicative of neurological impairment due to elevated pressure within the skull.

Choice B Reason:

The client has ecchymosis around the eyes. Ecchymosis around the eyes (raccoon eyes) can occur with certain head injuries, but it's not a direct sign of increased intracranial pressure. It's more commonly associated with basilar skull fractures rather than specifically reflecting increased pressure within the skull.

Choice C Reason:

The client is unable to remember details of the motor-vehicle crash. Memory impairment or amnesia regarding the event can occur due to head trauma, but it might not directly correlate with an increase in intracranial pressure. It's more related to the effects of the injury on memory function.

Choice D Reason:

The client reports ringing in the ears. Tinnitus or ringing in the ears might occur in some cases of head trauma but is not a direct indicator of increased intracranial pressure. It might result from the impact of the injury or other associated factors.

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Correct Answer is C

Explanation

Choice A Reason:
Informing the client of the adverse effect of diarrhea is less common with clonidine use, especially in comparison to other side effects like dry mouth or skin irritation.
Choice B Reason:
Monitoring for weight loss isn't a primary concern specifically associated with transdermal clonidine use.
Choice C Reason:
Advise the client about increased dry mouth. Dry mouth is a common adverse effect of clonidine, including the transdermal form. Patients should be informed about this so they can manage it effectively, for example, by drinking plenty of water or using sugar-free gum or candy to stimulate saliva production.
Choice D Reason:
Hypopigmentation is not a commonly reported issue with transdermal clonidine patches. However, local skin irritation or rash can occur at the site of the patch.

A. Use a hair dryer to blow hot air into the cast to relieve itching. B. Perform neurovascular checks of the affected extremity every 2 hr. C. Position the fractured arm below the level of the client's heart. D. Immobilize the client's fingers using a hand splint.

Correct Answer is B

Explanation

Choice A Reason

Using a hair dryer to blow hot air into the cast is not recommended. It can cause burns, soften the cast material, or create hot spots, potentially leading to skin damage or discomfort for the client.

Choice B Reason:

Perform neurovascular checks of the affected extremity every 2 hours is correct. Performing neurovascular checks regularly is crucial to assess the circulation, sensation, and movement of the affected extremity. This monitoring helps identify any signs of compromised blood flow or nerve function, which could indicate complications such as compartment syndrome.

Choice C Reason:

Positioning the fractured arm below the level of the client's heart is not advisable. Elevating the injured limb above heart level can help reduce swelling and promote blood flow, aiding in the healing process and preventing complications like swelling-related discomfort or decreased circulation.

Choice D Reason:

Immobilizing the client's fingers using a hand splint might not be necessary with a short arm cast. Typically, a short arm cast provides immobilization of the wrist and forearm while allowing some movement and function of the fingers unless specifically directed by the healthcare provider for individual circumstances.

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A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash. For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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