The nurse is caring for a client who sustained a head injury in a motor vehicle accident and is diagnosed with a subdural hematoma and increased intracranial pressure. Which nursing intervention is appropriate for this client?

Keeping the room brightly lit.

Encouraging coughing and deep breathing exercises.

Placing the client in a supine position.

Implementing seizure precautions.

Answer and Explanation

The Correct Answer is D

A. Keeping the room brightly lit can be overstimulating and may increase ICP; therefore, a calm, dimly lit environment is preferable.
B. Encouraging coughing and deep breathing exercises could increase ICP and should be avoided unless specifically indicated.
C. Placing the client in a supine position is not recommended for clients with increased ICP; they should typically be positioned with the head elevated to promote venous drainage.
D. Implementing seizure precautions is critical as head injuries can lead to seizures, and ensuring the client's safety is a priority.

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Correct Answer is ["A","C","D"]

Explanation

A. Calcium binders are used to help decrease the amount of calcium absorbed from the gastrointestinal tract, thus lowering calcium levels in the blood.
B. Vitamin D supplements would actually increase calcium levels by enhancing intestinal absorption, so this option is not appropriate in hypercalcemia.
C. Administering fluids helps to dilute serum calcium levels and promote renal excretion of calcium, making it a priority treatment.
D. Furosemide (Lasix) can help promote diuresis, thereby increasing the excretion of calcium through the urine, which is beneficial in managing hypercalcemia.
E. Oral phosphates may be used in some cases to manage hypercalcemia, but they are not a first-line treatment and their administration should be carefully considered in conjunction with other treatments.

A. Assess the client's respiratory status and airway patency. B. Assess the client's extremity strength and sensation. C. Assess the client's pain level and provide pain management. D. Assess the client's level of consciousness and orientation.

Correct Answer is A

Explanation

A. Assessing respiratory status and airway patency is the highest priority in this situation due to the risk of respiratory compromise from cervical spinal cord injuries, which can affect the diaphragm and other respiratory muscles.
B. While assessing extremity strength and sensation is important, it comes after ensuring the client’s airway and breathing are stable.
C. Pain management is essential, but addressing immediate life-threatening conditions takes precedence over pain assessment.
D. Assessing the client's level of consciousness is crucial for overall evaluation but does not take priority over ensuring adequate respiratory function in the context of a cervical spinal cord injury.

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The nurse is caring for a client who sustained a head injury in a motor vehicle accident and is diagnosed with a subdural hematoma and increased intracranial pressure. Which nursing intervention is appropriate for this client?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with hyperparathyroidism and hypercalcemia. The nurse should expect to administer which of the following priority treatments? SELECT ALL THAT APPLY.

Correct Answer is ["A","C","D"]

Explanation

A nurse is in the emergency department (ED) and is caring for a client that has arrived by ambulance after a cervical spinal cord injury. Which assessment should be the priority for the nurse to perform at this time?

Correct Answer is A

Explanation

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