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 D
Explanation
Herpes remains dormant in the body and can recur at any time, which is important information for the nurse to understand when discussing sexually transmitted infections with clients.
Gonorrhea, chlamydia, and syphilis can be treated with antibiotics, so they do not remain dormant in the body.
Correct Answer is A
Explanation
Exposing the affected area to air. Exposing the affected area to air is appropriate because it allows the skin to breathe and reduces the risk of skin breakdown. The client should be instructed to change the pad frequently and wash the perineal area with mild soap and water.
Option B, avoiding the application of moisture sealant, may increase the risk of skin breakdown.
Option C, avoiding using an electric room deodorizer, is not related to the situation.
Option D, using scented sprays or perfumes, may cause skin irritation.
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