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

Answer and Explanation

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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Correct Answer is ["B","C","D","E"]

Explanation

A. Early-onset dementia is a neurodegenerative condition that leads to cognitive decline but does not cause cerebral edema.
B. A benign brain tumor can increase intracranial pressure and cause localized or generalized cerebral edema due to mass effect.
C. Traumatic brain injury frequently leads to cerebral edema as a result of tissue damage and inflammation.
D. Bacterial meningitis can lead to inflammation of the brain and meninges, often resulting in cerebral edema.
E. Hemorrhagic stroke causes bleeding into the brain tissue, triggering inflammation and swelling (edema) around the affected area.

A. Log-rolls the client onto a slider board to transfer to the CT table B. Applies a hemostatic dressing over a bleeding facial laceration C. Inserts large-bore peripheral IVS for administration of IV contrast D. Administers PRN lorazepam for client reports of claustrophobia

Correct Answer is A

Explanation

A. Log-rolling maintains spinal alignment and prevents further injury when moving a client with a suspected cervical spine injury; this is the highest priority action.
B. Controlling bleeding is important but secondary to preventing spinal cord damage.
C. IV access is necessary for contrast administration but does not take priority over spinal precautions.
D. Managing anxiety is helpful but should not delay safe transfer and spinal precautions

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with cerebral edema. Which of the following should the nurse recognize as a potential cause of cerebral edema? (Select All that Apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is preparing a client with a possible cervical spine injury for a prescribed CT scan of the head and neck after the client sustained a fall down a stairwell. Which intervention by the nurse is the most important?

Correct Answer is A

Explanation

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