The nurse is caring for a client with a traumatic brain injury following a motor vehicle collision. The client is completely unresponsive to verbal or physical stimuli and does not open the eyes. Which prescription should the nurse clarify with the health care provider?
Infuse 0.45% sodium chloride at a rate of 100 mL/hr
Insert indwelling urinary catheter and monitor urine output hourly
Place the client in semi-Fowler position with head in neutral alignment
Prepare equipment and medications for emergency endotracheal intubation
The Correct Answer is A
A. Hypotonic solutions like 0.45% sodium chloride can increase cerebral edema by shifting fluid into brain cells, which is dangerous in clients with increased intracranial pressure (ICP). This prescription should be clarified to avoid worsening the brain injury.
B. Hourly urine output monitoring is appropriate in critically ill or neurologically impaired clients to assess renal perfusion and detect complications such as diabetes insipidus.
C. Semi-Fowler position with the head in neutral alignment helps reduce ICP and is the recommended positioning for clients with brain injuries.
D. The client's unresponsiveness indicates a compromised airway or risk of deterioration, making preparation for intubation appropriate and necessary.
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Related Questions
Correct Answer is D
Explanation
A. Sims' position is primarily used for rectal exams and enemas, and does not specifically help reduce ICP.
B. Trendelenburg position (head lower than feet) can increase ICP and is contraindicated.
C. Prone position can increase intracranial pressure due to impaired venous drainage.
D. Semi-Fowler’s position (head elevated 30–45 degrees) promotes venous drainage from the brain, helping to reduce ICP and improve patient comfort.
Correct Answer is A
Explanation
A. Neurogenic shock is a common complication of spinal cord injuries above T6, including T4, due to disruption of sympathetic pathways causing hypotension, bradycardia, and vasodilation.
B. Malignant hyperthermia is a rare genetic reaction to certain anesthetics, unrelated to spinal cord injury.
C. Neuroleptic malignant syndrome is a reaction to antipsychotic drugs, not related to spinal cord injury.
D. Tardive dyskinesia is a side effect of long-term antipsychotic use, unrelated to spinal cord injury.
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