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 B

Explanation

A. Insufficient insulin production is related to diabetes mellitus, not Cushing's syndrome.
B. Long-term use of glucocorticoids is a well-known exogenous cause of Cushing's syndrome, as it leads to excess cortisol in the body.
C. Adrenal insufficiency refers to a deficiency of adrenal hormones and would not cause Cushing's syndrome, which is characterized by excess hormones.
D. Overproduction of growth hormones is associated with acromegaly or gigantism, not Cushing's syndrome, which primarily involves excess cortisol.

A. Encourage fluid intake at and between meals. B. Cleanse the perineum from back to front. C. Offer the client the bedpan every 2 hours. D. Obtain a prescription for an indwelling urinary catheter.

Correct Answer is A

Explanation

A. Encouraging fluid intake at and between meals helps to dilute urine and can reduce the risk of urinary tract infections (UTIs) by promoting regular urination.
B. Cleansing the perineum should be done from front to back to prevent the introduction of bacteria from the rectal area to the urethra, so this option is incorrect.
C. Offering the bedpan every 2 hours may not be sufficient for individuals at risk for UTIs, as more frequent voiding can help prevent infection.
D. An indwelling urinary catheter increases the risk of urinary tract infections and should be avoided unless absolutely necessary; intermittent catheterization is generally preferred for those with spinal cord injuries to minimize this risk.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client with Cushing's syndrome. The nurse is aware that an exogenous cause of Cushing's syndrome is which of the following?

Correct Answer is B

Explanation

A nurse is planning care for a client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care?

Correct Answer is A

Explanation

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