The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Auscultate breath sounds to assess for crackles

Press over the tibia to assess for pitting edema

Monitor Glasgow Coma Scale increasing from 8/15 to 9/15

Monitor for >50 mL/hr urine output

Answer and Explanation

The Correct Answer is A

A. Mannitol is an osmotic diuretic that pulls fluid from brain tissue into the vascular space, which can lead to fluid overload and pulmonary edema. Crackles on auscultation may indicate this complication and should be assessed.
B. While peripheral edema may occur with fluid overload, crackles are a more immediate and concerning sign of pulmonary congestion related to mannitol.
C. An increase in Glasgow Coma Scale score indicates improvement in neurologic function, not a complication.
D. Increased urine output is an expected effect of mannitol; it helps reduce ICP by promoting diuresis.

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Correct Answer is D

Explanation

A. Physical therapists focus on mobility and muscle strength but are not primarily responsible for preventing the leading cause of death.
B. Occupational therapists assist with activities of daily living but do not address the highest mortality risk directly.
C. Nutrition is important for overall health but not the primary factor in preventing the leading cause of death in spinal cord injury patients.
D. Respiratory complications are the leading cause of death in clients with spinal cord injuries due to impaired respiratory muscle function. Collaboration with respiratory therapists is essential to monitor, prevent, and manage respiratory issues.

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

Correct Answer is C

Explanation

A. Bladder distention is a common trigger of autonomic dysreflexia, but the immediate priority is to reduce blood pressure by positioning the patient.
B. Antihypertensive medication may be necessary, but nonpharmacologic interventions such as positioning and removing the triggering stimulus should be done first.
C. Placing the client in a high-Fowler’s position is the first action to lower blood pressure by promoting venous pooling in the lower extremities, thereby reducing cerebral blood pressure and minimizing the risk of stroke.
D. Heart rate monitoring is part of the assessment but does not take priority over immediately addressing the dangerously high blood pressure.

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The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which member of the interprofessional health care team is a nursing priority?

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 C

Explanation

A nurse is preparing a client with a possible cervical spine injury for a prescribed CT scan of the head and neck after the client sustained a fall down a stairwell. Which intervention by the nurse is the most important?

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