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

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.

A. Hypotension B. Dehydration C. Hyponatremia D. Hypokalemia

Correct Answer is D

Explanation

A. Hypotension is not typically associated with adrenal cortex hyperfunction; in fact, patients may experience hypertension due to excess cortisol and aldosterone.
B. Dehydration is more common with adrenal insufficiency than hyperfunction, as excess hormone production often leads to fluid retention.
C. Hyponatremia is generally not a concern with adrenal cortex hyperfunction; clients may experience hypernatremia instead due to fluid retention.
D. Hypokalemia is a significant risk in clients with adrenal cortex hyperfunction, especially due to the effects of excessive aldosterone, which promotes sodium retention and potassium excretion.

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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 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

A nurse is caring for a client with Adrenal Cortex Hyperfunction. The nurse is aware that the client is at risk for which of the following?

Correct Answer is D

Explanation

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