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

a.A GCS score of 8 indicates severe impairment, suggesting the client may be in a state where they cannot perform basic self-care activities and thus require total nursing care.

b.A GCS score of 8 indicates severe impairment but not necessarily a deep coma. Scores below 8 suggest a comatose state, but deep coma is more likely to be indicated by a score of 3-4.

c.A GCS score of 8 is not consistent with a client who is alert and oriented. This score indicates significant neurological impairment.

d.A GCS score of 8 does not indicate stable neurological status. It suggests severe impairment and potentially unstable or deteriorating neurological condition.

A. Peripheral edema B. Diarrhea C. Decreased pedal pulses D. Hypertension

Correct Answer is D

Explanation

A nurse collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm should monitor the client for hypertension as a manifestation of increased intracranial pressure. Increased intracranial pressure can cause changes in blood pressure, including hypertension.

a. Peripheral edema is not a manifestation of increased intracranial pressure. Peripheral edema is swelling in the extremities and can be caused by a variety of conditions.

b. Diarrhea is not a manifestation of increased intracranial pressure. Diarrhea is loose or watery stools and
can be caused by a variety of conditions.

c. Decreased pedal pulses are not a manifestation of increased intracranial pressure. Decreased pedal
pulses can indicate poor circulation to the feet and can be caused by a variety of conditions.

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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

A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

Correct Answer is D

Explanation

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