The nurse is caring for a client who sustained a moderate head injury following a bicycle accident.

The nurse's most recent assessment reveals that the client's respiratory effort has increased.

What is the nurse's most appropriate action?

Administer a bolus of normal saline as prescribed.

Administer bronchodilators as prescribed and monitor the client's LOC.

Increase the client's bed height and reassess in 30 minutes.

Inform the care team and assess for further signs of possible increased ICP.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Administering a bolus of normal saline may not directly address the cause of increased respiratory effort, which could be related to increased intracranial pressure (ICP). Normal saline administration is not the priority intervention in this case.

Choice B rationale

Bronchodilators are used to manage bronchoconstriction, not increased respiratory effort due to potential increased ICP. Monitoring the client's level of consciousness (LOC) is important, but bronchodilators are not indicated here.

Choice C rationale

Increasing the client's bed height can help with respiratory effort, but it does not directly address the potential underlying issue of increased ICP. Reassessing in 30 minutes might delay necessary interventions.

Choice D rationale

Increased respiratory effort in a client with a head injury may indicate rising ICP. Informing the care team and assessing for further signs of increased ICP is crucial for timely intervention to prevent further complications.

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Correct Answer is C

Explanation

Choice A rationale

Furuncles, also known as boils, are deep folliculitis caused by bacterial infection, not sebum blockage.

Choice B rationale

Carbuncles are clusters of furuncles connected under the skin and are also caused by bacterial infection, not sebum blockage.

Choice C rationale

Comedones are primary lesions of acne caused by the blockage of hair follicles by sebum and keratin. They can be open (blackheads) or closed (whiteheads).

Choice D rationale

Striae, also known as stretch marks, are caused by the tearing of the dermis due to rapid stretching of the skin and are not related to sebum blockage in hair follicles.

A. Wash hands, apply a pediculicide to the client's scalp, and remove any observable mites. B. Place the client on enteric precautions. C. Isolate the client's bed linens until the client is no longer infectious. D. Notify the nurse in the day surgery unit of a potential scabies outbreak.

Correct Answer is C

Explanation

Choice A rationale

Pediculicides are used to treat lice, not scabies. Proper hand hygiene is important, but applying pediculicide is not necessary for scabies management.

Choice B rationale

Enteric precautions are for infections transmitted via the fecal-oral route, not for scabies, which requires contact precautions.

Choice C rationale

Isolating the client's bed linens and applying contact precautions help prevent the spread of scabies to other clients.

Choice D rationale

Notifying the day surgery unit of a potential scabies outbreak is important, but it does not directly prevent infection in other clients.

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The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

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Naxlex Comprehensive Predictor Exams

Which primary lesions are associated with acne caused by sebum blockage in hair follicles?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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The nurse is caring for a client who sustained a moderate head injury following a bicycle accident.

The nurse's most recent assessment reveals that the client's respiratory effort has increased.

What is the nurse's most appropriate action?