A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?

Apply heat to the area of swelling for the first 48 hr.

Repeatedly ask the client questions to check for orientation.

Do not let the client engage in strenuous activities for 1 week.

Encourage the client to sleep for the first 24 hr.

Answer and Explanation

The Correct Answer is C

The nurse should instruct the family to not let the client engage in strenuous activities for 1 week following a minor head injury. This can help prevent further injury and allow the client to rest and recover.

Applying heat to the area of swelling for the first 48 hr, repeatedly asking the client questions to check for orientation, and encouraging the client to sleep for the first 24 hr are not appropriate instructions for the nurse to include in this situation. Applying heat can increase swelling and inﬂammation. Repeatedly asking the client questions can be disorienting and confusing. Encouraging the client to sleep for the first 24 hr is not necessary and could interfere with monitoring the client's condition.

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Correct Answer is A

Explanation

The nurse should tell the newly licensed nurse that Russell's traction uses a sling under the knee to treat a fracture of the femur. Russell's traction is a type of skin traction that is used to immobilize and align a fractured femur. It involves placing a sling under the knee and applying weights to the aﬀected leg to provide continuous traction.

Russell's traction does not use a cervical halter, skeletal pins, or a pelvic girdle belt. A cervical halter is used to treat neck injuries. Skeletal pins are used in skeletal traction to stabilize fractures. A pelvic girdle belt is used to treat lower back pain.

A. Check the client for injuries. B. Obtain a prescription for medication to sedate the client. C. Call the family and ask them to make arrangements for someone to sit with the client. D. Assist the client back into bed and apply restraints.

Correct Answer is A

Explanation

The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.

Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.

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A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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