The charge nurse observes a new graduate nurse who is caring for a client who has a severe head injury. Which action by the new graduate nurse requires the charge nurse to intervene?

The new graduate nurse elevates the client's head of the bed to 30 degrees.

The new graduate nurse administers an analgesic before turning the client.

The new graduate nurse is frequently suctioning the client without breaks.

The new graduate nurse assesses the client's neurologic status every hour.

Answer and Explanation

The Correct Answer is C

A. The new graduate nurse elevates the client's head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees helps reduce ICP by promoting venous drainage from the brain.

B. The new graduate nurse administers an analgesic before turning the client. Analgesics are often necessary before turning a client with a head injury to minimize discomfort and prevent additional stress.

C. The new graduate nurse is frequently suctioning the client without breaks: Frequent suctioning without breaks can increase intracranial pressure (ICP) and compromise the patient's condition. Suctioning should be done with caution and only as needed, allowing for breaks in between to prevent ICP elevation.

D. The new graduate nurse assesses the client's neurologic status every hour. Regular neuro assessments are necessary for patients with head injuries to monitor changes in condition.

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Correct Answer is C

Explanation

A. Intermittent claudication and pallor: These symptoms are more indicative of peripheral vascular disease, not a myocardial infarction.

B. Jugular vein distention and dependent edema. These symptoms suggest right-sided heart failure or fluid overload, not myocardial infarction.

C. Diaphoresis and cool, clammy skin. Diaphoresis (sweating) and cool, clammy skin are common signs of myocardial infarction due to the body's response to pain and decreased cardiac output.

D. Mid-epigastric pain and heartburn. While heartburn can mimic some symptoms of a heart attack, mid-epigastric pain and heartburn are more likely to be related to gastrointestinal issues rather than myocardial infarction.

A. Propranolol B. Procainamide C. Aspirin D. Warfarin

Correct Answer is D

Explanation

A. Propranolol: This is a beta-blocker, which may be used to control heart rate, but it does not address the risk of thromboembolism in atrial fibrillation.

B. Procainamide: This is an antiarrhythmic used for rhythm control, but it does not address stroke prevention in atrial fibrillation.

C. Aspirin: Although aspirin is sometimes used for stroke prevention, it is generally less effective than anticoagulation therapy in clients with higher CHA2DS2-VASC scores.

D. Warfarin: A CHA2DS2-VASC score of 2 indicates a moderate risk for stroke, and warfarin (or another anticoagulant) is indicated to reduce the risk of thromboembolic events.

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The charge nurse observes a new graduate nurse who is caring for a client who has a severe head injury. Which action by the new graduate nurse requires the charge nurse to intervene?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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