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
drug allergy. A skin rash is a common symptom of an allergic reaction to a medication, and a drug allergy can occur at any time during drug therapy. A drug allergy may be due to an immune response, causing the immune system to overreact to a medication that it identifies as harmful to the body. The symptoms of a drug allergy may include a rash, hives, itching, or difficulty breathing. It is important for the nurse to determine which medication the client is taking and if the client has a history of allergies.
Heat stroke (B) occurs when the body is exposed to high temperatures, leading to symptoms such as high body temperature, confusion, and loss of consciousness. Hormone changes (C) can cause various changes in the body but do not usually cause skin rashes. A suntan (D) is a reaction of the skin to ultraviolet light and is not a cause of a skin rash.
Correct Answer is C
Explanation
Hypovolemia. Following a serious thermal burn, the nurse takes action to prevent hypovolemia, which can result from fluid loss due to the burn. Hypovolemia can lead to hypoperfusion of vital organs, including the kidneys, and can cause acute renal failure. Preventing hypovolemia is critical to preventing other complications such as tissue hypoxia, cardiac failure, and infection.
A. Tissue hypoxia and cardiac failure are consequences of hypovolemia due to decreased blood flow to organs.
D. Infection is not the immediate complication to prevent but is a potential complication following burn injury.
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