A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)

Infection

Vomiting

Widening pulse pressure

Equal and reactive pupils

Intracranial pressure reading of 10 mm Hg

Answer and Explanation

Correct Answer : A,B,C

Choice A Reason:

Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.

Choice B Reason:

Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.

Choice C Reason:

Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.

Choice D Reason:

Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.

Choice E Reason:

An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.

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Correct Answer is B

Explanation

Choice A Reason

Apply an ice pack directly to the affected area. This statement is incorrect. Applying ice to a snake bite can cause more harm than good. Ice can restrict blood flow and potentially increase tissue damage. The recommended approach is to keep the bite area still and at or below heart level to slow the spread of venom.

Choice B Reason

Immobilize the affected extremity with a splint. This is the correct intervention. Immobilizing the affected limb helps to slow the spread of venom by reducing movement. Keeping the limb still and using a splint can prevent the venom from circulating more rapidly through the body.

Choice C Reason

Place a tourniquet above and below the affected area. This statement is incorrect. Using a tourniquet is not recommended for snake bites as it can cause severe damage to the affected limb by cutting off blood flow completely. This can lead to tissue death and other complications.

Choice D Reason

Elevate the affected extremity. This statement is incorrect. Elevating the limb can increase the spread of venom. The affected limb should be kept at or below heart level to slow the venom’s spread.

A. “Avoid strenuous activities for 1 week following the procedure.” B. “You will lie on your back during the procedure.” C. “You will receive general anesthesia for the procedure.” D. “Take acetaminophen as prescribed for pain relief after the procedure.”

Correct Answer is D

Explanation

Choice A Reason

“Avoid strenuous activities for 1 week following the procedure.” This statement is partially correct. While it is advisable to avoid strenuous activities, the exact duration can vary. Typically, patients are advised to avoid heavy lifting and vigorous activities for a few days to a week, depending on their recovery.

Choice B Reason

“You will lie on your back during the procedure.” This statement is incorrect. For a bone marrow biopsy from the iliac crest, the patient usually lies on their side or stomach to allow access to the hip bone. Lying on the back would not provide the necessary access for the procedure.

Choice C Reason

“You will receive general anesthesia for the procedure.” This statement is incorrect. Bone marrow biopsies are usually performed under local anesthesia to numb the area. General anesthesia is not typically required. The patient may also receive a mild sedative to help them relax.

Choice D Reason

“Take acetaminophen as prescribed for pain relief after the procedure.” This is the correct statement. Acetaminophen is commonly recommended for pain relief after a bone marrow biopsy because it is effective and has fewer side effects compared to other pain medications like NSAIDs, which can increase the risk of bleeding.

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A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a rural community is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who is scheduled for a bone marrow biopsy taken from the iliac crest. Which of the following information should the nurse include?

Correct Answer is D

Explanation

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