The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?
The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg.
The client has periorbital edema and ecchymosis.
The client prefers to rest in the semi-Fowler's position.
The client's level of consciousness has improved.
The Correct Answer is A
The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg. An elevated temperature is a significant finding that may indicate the presence of an infection, which can cause further neurological damage in a client with an intracranial injury. The physician should be notified promptly, as the client may require antibiotic therapy to prevent the spread of infection.
B. Periorbital edema and ecchymosis are normal findings following head injury and should be monitored but do not require immediate intervention.
C. Resting in semi-Fowler's position is an appropriate position to maintain after intracranial pressure-reducing surgery.
D. Improved level of consciousness is a positive finding and indicates that the client is responding well to treatment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.
Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.
Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.
Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.
Correct Answer is A
Explanation
Hyperkalemia. Confusion, abdominal cramping, racing heart rate, and numbness of the extremities are symptoms associated with hyperkalemia, a condition where the potassium level in the blood is too high.
Hypocalcemia, choice B, is characterized by muscle spasms, numbness, and tingling around the mouth and fingertips.
Elevated urea levels, choice C, may be associated with decreased urine output, fatigue, and shortness of breath.
Elevated white blood cells, choice D, may indicate an infection.
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