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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A warm sensation. The most common sensation experienced when a contrast agent is injected into the body during diagnostic studies is a warm sensation, as the contrast agent causes a temporary increase in blood flow to the injected area.
Option B, Light-headedness, is not the most common sensation experienced during diagnostic studies with contrast agents.
Option C, Heart palpitations, are not common sensations experienced during diagnostic studies with contrast agents.
Option D, Chills, are not common sensations experienced during diagnostic studies with contrast agents.
Correct Answer is B
Explanation
Choice A is incorrect because stuporous is a state of reduced consciousness, and does not describe the posturing observed in the client.
Choice B is correct because decerebrate posturing is characterized by extension of the arms, wrists, and fingers, and extension and internal rotation of the legs, with plantar flexion of the feet.
Choice C is incorrect - Decorticate posturing is characterized by flexion of the arms, wrists, and fingers, extension, internal rotation, and adduction of the legs, with plantar flexion of the feet. This is caused by damage to the cerebral cortex and is indicative of a neurological problem.
Choice D is incorrect because flaccidity is a state of complete lack of muscle tone, and does not describe the posturing observed in the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.