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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.

Answer and Explanation

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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Correct Answer is D

Explanation

Radical excision. Treatment of melanoma includes surgical excision of the tumor with a margin of normal tissue to decrease the risk of recurrence. Radical excision involves the removal of the tumor, adjacent tissue, and possibly lymph nodes.

Option A, radiation therapy, may be used as an adjunct therapy, but it is not the primary treatment.

Option B, laser surgery, may be used to remove superficial lesions, but not for melanoma.

Option C, cryosurgery, is used to remove benign lesions or precancerous cells, but not for melanoma.

A. Place end of tube in water and observe for bubbling. B. Using auscultation technique. C. Measure pH of aspirates. D. Radiographic confirmation.

Correct Answer is D

Explanation

Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.

Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.

Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.

Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.

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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?

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Naxlex Comprehensive Predictor Exams

Treatment of melanoma includes which of the following?

Correct Answer is D

Explanation

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Correct Answer is D

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