A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?
Administer opioids.
Darken the room.
Apply restraints.
Reduce stimuli.
The Correct Answer is D
Choice A Reason: This is incorrect. Opioids are not indicated for a client who is emerging from a coma, as they can cause respiratory depression, sedation, and confusion. They may also mask the signs of increased intracranial pressure or neurological deterioration.
Choice B Reason: This is incorrect. Darkening the room may not be helpful for a client who is emerging from a coma, as it may increase their disorientation and agitation. The nurse should provide adequate lighting and orient the client to time, place, and person frequently.
Choice C Reason: This is incorrect. Applying restraints may worsen the restlessness and agitation of a client who is emerging from a coma, as they may perceive them as a threat or a restriction. Restraints may also increase the risk of injury, infection, or skin breakdown. The nurse should use restraints only as a last resort and with a physician's order.
Choice D Reason: This is correct. Reducing stimuli is an appropriate intervention for a client who is emerging from a coma, as it can help calm them and prevent sensory overload. The nurse should limit noise, visitors, and unnecessary procedures, and provide a quiet and comfortable environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason: This is correct because smallpox is a highly contagious and deadly viral disease that can be used as a biological weapon. Smallpox was eradicated in 1980, but some samples of the virus are still stored in laboratories. If released intentionally, smallpox could cause a global pandemic.
Choice B Reason: This is incorrect because hydrogen cyanide is a chemical weapon of mass destruction, not a biological one. Hydrogen cyanide is a colorless gas that interferes with cellular respiration and causes rapid death.
Choice C Reason: This is correct because botulism is a serious and potentially fatal illness caused by a toxin produced by the bacterium Clostridium botulinum. Botulism can be used as a biological weapon by contaminating food or water supplies or by aerosolizing the toxin.
Choice D Reason: This is correct because anthrax is an infection caused by the spore-forming bacterium Bacillus anthracis. Anthrax can be used as a biological weapon by releasing the spores into the air or by contaminating food or water sources.
Choice E Reason: This is incorrect because sarin is a chemical weapon of mass destruction, not a biological one. Sarin is a nerve agent that blocks the transmission of nerve impulses and causes respiratory failure and death.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect. The balloons should not be deflated without a physician's order, as this can cause rebleeding or aspiration.
Choice B Reason: This is incorrect. The head of the bed should be elevated to 30 to 45 degrees to reduce pressure on the balloons and prevent gastric reflux.
Choice C Reason: This is correct. The nurse should monitor the client closely for signs of complications, such as airway obstruction, aspiration, or balloon rupture. The nurse should also keep scissors at the bedside to cut the tube and release the balloons in case of an emergency.
Choice D Reason: This is incorrect. The tube should not be suctioned, as this can damage the mucosa and cause bleeding. The nurse should only aspirate gastric contents through the gastric lumen to decompress the stomach.
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