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

The peripheral nervous system (PNS) consists of all the nerves outside the brain and spinal cord. It transmits signals to and from the central nervous system but does not specifically regulate energy expenditure.

Choice B rationale

The parasympathetic nervous system is part of the autonomic nervous system that promotes "rest and digest" functions, conserving energy by slowing the heart rate and increasing intestinal and gland activity.

Choice C rationale

The sympathetic nervous system is responsible for the "fight or flight" response, which prepares the body to expend energy rapidly in response to perceived threats. It increases heart rate, dilates airways, and mobilizes energy stores.

Choice D rationale

The central nervous system (CNS) consists of the brain and spinal cord. It is responsible for processing information and coordinating bodily functions but does not specifically regulate energy expenditure.

A. Dysfunction in the cerebrum. B. Dysfunction in the brain stem. C. Dysfunction in the spinal column. D. Dysfunction in the motor cortex.

Correct Answer is B

Explanation

Choice A rationale

Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.

Choice B rationale

Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.

Choice C rationale

Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.

Choice D rationale

Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

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?