Here is the edited text:
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

Administer a vasodilator medication.

Elevate the head of the bed to 30°.

Apply a cold compress to the forehead.

Decrease the oxygen ﬂow rate.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This choice is incorrect because administering a vasodilator medication may lower the blood pressure and worsen the cerebral perfusion. A vasodilator medication is a drug that relaxes the blood vessels and reduces the resistance to blood ﬂow. It may be used for clients who have hypertension, angina, or heart failure, but it does not help to reduce the intracranial pressure (ICP).

Choice B Reason: This choice is correct because elevating the head of the bed to 30° may help to improve the venous drainage and decrease the ICP. ICP is the pressure exerted by the brain tissue, cerebrospinal ﬂuid (CSF), and blood within the cranial cavity. A normal ICP range is 5 to 15 mm Hg, and an elevated ICP (>20 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, positioning the client in a semi-Fowler's position (30° angle) or high- Fowler's position (60° to 90° angle) can facilitate breathing and prevent further complications.

Choice C Reason: This choice is incorrect because applying a cold compress to the forehead may cause vasoconstriction and increase the ICP. A cold compress is a device that applies cold temperature to a body part to reduce inﬂammation, pain, or swelling. It may be used for clients who have headaches, sprains, or bruises, but it does not help to reduce the ICP.

Choice D Reason: This choice is incorrect because decreasing the oxygen ﬂow rate may cause hypoxia and worsen the cerebral ischemia. Hypoxia is a condition in which the body or a part of it does not receive enough oxygen. It may cause symptoms such as confusion, agitation, or cyanosis. Therefore, providing adequate oxygenation and ventilation is essential to maintain the brain function and prevent further damage.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.

Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreﬂexia or relieve the symptoms.

Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreﬂexia.

Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.

A. Administer a nitrate antihypertensive. B. Obtain the client's heart rate. C. Assess the client for bladder distention. D. Place the client in a high-Fowler's position.

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.

Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreﬂexia or relieve the symptoms.

Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreﬂexia.

Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.

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Here is the edited text: A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreﬂexia. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Here is the edited text:
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?