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 C

Explanation

A. Diplopia is a concerning symptom but does not indicate immediate deterioration in neurological status like a change in GCS does.
B. Ataxia is also significant but is less acute than a drop in GCS score.
C. A change in the Glasgow Coma Scale score from 13 to 11 indicates a worsening level of consciousness and necessitates immediate reporting, as it may suggest increased intracranial pressure or other complications.
D. A decrease in heart rate from 76 to 69 bpm is not significant enough in the context of TBI to warrant immediate reporting, as it remains within a normal range.

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

Correct Answer is C

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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