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 B

Explanation

Choice A Reason: Preventing musculoskeletal disability is important, but not the priority focus of care. The nurse should first assess and manage the client's life-threatening injuries, such as airway obstruction, bleeding, shock, or brain injury.

Choice B Reason: Airway protection is the priority focus of care for a client with multiple system trauma. The nurse should ensure that the client has a patent airway and adequate ventilation, as any compromise in these areas can quickly lead to hypoxia, respiratory failure, and death.

Choice C Reason: Stabilizing cardiac arrhythmias is also important, but not the priority focus of care. The nurse should monitor the client's cardiac rhythm and treat any arrhythmias that may occur, but only after securing the airway and breathing.

Choice D Reason: Decreasing intracranial pressure is another important goal, but not the priority focus of care. The nurse should assess the client's neurological status and intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

A. Fluid overload B. Intracardiac shunt C. Hypovolemia D. Left ventricular failure

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because ﬂuid overload is a condition of excess ﬂuid volume in the body. A client who has ﬂuid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.

Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood ﬂow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.

Choice C Reason: This is correct because hypovolemia is a condition of low ﬂuid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.

Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.

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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?

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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?