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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale
Tachycardia is not a symptom of Cushing's triad; it is often associated with other conditions such as stress or heart problems.
Choice B rationale
Bradypnea is a hallmark of Cushing's triad, indicating decreased respiratory rate due to increased intracranial pressure.
Choice C rationale
Hypertension is a key component of Cushing's triad, caused by increased intracranial pressure leading to elevated blood pressure.
Choice D rationale
Bradycardia, or a slower than normal heart rate, is a symptom of Cushing's triad, resulting from increased pressure in the brain affecting the heart rate.
Choice E rationale
Pupillary constriction is not typically associated with Cushing's triad; it is usually related to other neurological conditions.
Correct Answer is D
Explanation
Choice A rationale
Interactive dressings are designed to interact with the wound environment to promote healing. These can include dressings that release medication or create an optimal moisture balance. They are not typically used for acutely inflamed and oozing skin lesions.
Choice B rationale
Passive dressings are protective covers that keep the wound clean and protected from external contaminants. They do not have additional properties to manage wound exudate or inflammation.
Choice C rationale
Protective dressings are generally used to shield wounds from further injury or contamination. They do not specifically address the needs of an oozing and inflamed lesion.
Choice D rationale
Occlusive dressings are designed to maintain a moist wound environment, which can aid in the healing of oozing wounds. They can also provide a barrier to external contaminants and help manage exudate effectively, making them suitable for acutely inflamed and oozing lesions.
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