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 D
Explanation
Choice A rationale
Pressing the bones on the neck does not adequately assess for rigidity and may cause discomfort without providing useful information about the neurologic status.
Choice B rationale
Moving the head toward both sides is a method used to assess range of motion but does not specifically assess for neck rigidity, which requires specific positioning and movement.
Choice C rationale
Lightly tapping the lower portion of the neck to detect sensation does not assess for rigidity; it may be used to test sensory function rather than muscular stiffness or tension.
Choice D rationale
Moving the head and chin toward the chest is the standard method to assess for neck rigidity, especially in cases of suspected meningitis. This movement can reveal stiffness or resistance, which are key indicators of neurologic involvement.
Correct Answer is B
Explanation
Choice A rationale
The Romberg test does not assess motor ability. Motor ability tests typically involve assessing muscle strength, coordination, and movement.
Choice B rationale
The Romberg test is used to assess balance. It evaluates the client's ability to maintain a steady position with eyes closed, indicating the integrity of the proprioceptive and vestibular systems.
Choice C rationale
The Romberg test does involve coordination, but its primary focus is on balance rather than coordination alone. Coordination tests usually involve tasks requiring fine motor control.
Choice D rationale
The Romberg test does not assess muscle strength. Muscle strength tests involve evaluating the force generated by muscles during contraction.
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