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 ["C","D"]
Explanation
Choice A rationale
The trigeminal nerve is responsible for facial sensation and motor functions like chewing, not related to gag reflex impairment.
Choice B rationale
The facial nerve controls facial expressions, taste sensations, and other functions but does not influence the gag reflex.
Choice C rationale
The glossopharyngeal nerve (cranial nerve IX) plays a crucial role in the gag reflex as it innervates part of the pharynx and is responsible for sensory functions in the throat.
Choice D rationale
The vagus nerve (cranial nerve X) also contributes to the gag reflex, providing motor innervation to the pharyngeal muscles and aiding in swallowing and speech functions.
Correct Answer is C
Explanation
Choice A rationale
Cranial nerve VII (Facial nerve) controls muscles of facial expression and functions in taste sensations from the anterior two-thirds of the tongue, not balance.
Choice B rationale
Cranial nerve VI (Abducens nerve) controls lateral eye movement and has no role in balance or proprioception.
Choice C rationale
Cranial nerve VIII (Vestibulocochlear nerve) is responsible for hearing and balance. A positive Romberg test indicates issues with proprioception or vestibular function, which is directly linked to this nerve.
Choice D rationale
Cranial nerve IX (Glossopharyngeal nerve) involves taste sensation from the posterior third of the tongue and some swallowing functions, not balance.
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