The emergency department nurse is assessing a patient who has been in an automobile accident. Which clinical manifestation illustrates a tension pneumothorax?

A. Maintain head of bed elevation at 15 degrees or less: For a patient with increased intracranial pressure (ICP), the head of the bed should typically be elevated 30 degrees, not limited to 15 degrees. Proper elevation promotes venous drainage from the brain and helps reduce ICP, making 15 degrees insufficient for effective ICP management.

B. Provide oxygen therapy to maintain oxygen saturation above 92: Maintaining adequate oxygenation is critical in patients with neurological injury. Hypoxia can worsen cerebral ischemia and increase ICP, so oxygen therapy should be titrated to keep SpO₂ within the prescribed safe range, typically above 92%, to support cerebral perfusion and prevent secondary brain injury.

C. Keep lights dim in client's room to accommodate photophobia: While dim lighting can increase comfort in patients with migraine or photophobia, it does not directly affect ICP management. This action is supportive but not a priority intervention in caring for a patient with increased ICP.

D. Assess the client for headaches and behavior changes frequently: Frequent neurological assessment, including monitoring for changes in level of consciousness, behavior, and headache, is essential for early detection of worsening ICP or complications. These assessments guide timely interventions and are critical in intensive care management of post-stroke patients.

E. Minimize suctioning or hyper-oxygenate client before suctioning: Suctioning can stimulate coughing and increase ICP. To prevent sudden spikes in ICP, suctioning should be minimized and performed only when necessary, with pre-oxygenation to maintain cerebral oxygenation and reduce secondary brain injury risk.

A. Serum potassium 6.5 mEq/L: Hyperkalemia is a life-threatening electrolyte imbalance commonly seen in burn patients due to cellular destruction and release of intracellular potassium. A potassium level of 6.5 mEq/L can precipitate dangerous cardiac dysrhythmias, including ventricular fibrillation or asystole. Immediate nursing interventions include cardiac monitoring, notifying the healthcare provider, and preparing for treatments.

B. Hematocrit 52%: Elevated hematocrit reflects hemoconcentration, which is common in burn patients due to fluid shifts and plasma loss. While it indicates dehydration and ongoing fluid resuscitation needs, it is not immediately life-threatening and can be addressed with continued monitoring and IV fluids.

C. Serum sodium 146 mEq/L: A sodium level slightly above normal indicates mild hypernatremia, which can occur due to fluid shifts and inadequate free water replacement. Although it requires monitoring and adjustment of fluid therapy, it does not pose the same immediate risk as hyperkalemia.

D. Urine specific gravity 1.005: This value suggests dilute urine, which may indicate adequate hydration or early renal impairment. While it warrants monitoring in the context of burn resuscitation, it does not require urgent intervention compared with a dangerously high potassium level.