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 ["A","B","C","E"]

Explanation

A. Compartment syndrome: This is a serious complication that can occur with fractures, including femur fractures. It occurs when increased pressure in the muscle compartment impairs circulation and nerve function.

B. Hemorrhage: Fractures, particularly of long bones like the femur, can result in significant bleeding. Monitoring for hemorrhage is important.

C. Deep vein thrombosis (DVT): DVT is a common complication in clients with fractures and immobilization. The client is at risk for blood clots forming in the legs due to limited movement and prolonged bed rest.

D. Complex regional pain syndrome: While this can occur after fractures, it is less common and typically develops weeks to months after the injury.

E. Fat embolism: A fat embolism is a potential complication of long bone fractures, especially the femur. Fat globules can enter the bloodstream and cause respiratory distress, neurological impairment, and petechial rash.

A. Remind the client to look for food on the left side of the tray B. Provide a non-skid mat to alleviate plate movement. C. Encourage the client to use his right hand when feeding himself. D. Encourage the use of the wide grip utensils.

Correct Answer is A

Explanation

A. Remind the client to look for food on the left side of the tray: Homonymous hemianopsia is a condition in which a person loses vision in the same half of the visual field of each eye (in this case, the left visual field due to right-sided brain damage). The nurse should remind the client to look for food on the left side of the tray to help compensate for the visual deficit.

B. Provide a non-skid mat to alleviate plate movement. While a non-skid mat can help with plate stability, it does not address the visual field loss caused by homonymous hemianopsia.

C. Encourage the client to use his right hand when feeding himself. There is no specific benefit to using the right hand when a client is experiencing a visual deficit in the left visual field. Instead, compensating for the visual field loss is the priority.

D. Encourage the use of the wide grip utensils. Wide grip utensils are helpful for clients with limited hand mobility but will not address the specific visual impairment caused by homonymous hemianopsia.

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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

A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until his femur can be surgically repaired. What complications should the nurse monitor for? Select All That Apply

Correct Answer is ["A","B","C","E"]

Explanation

A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hernianopsia when eating. Which action should the nurse take?

Correct Answer is A

Explanation

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