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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Related Questions
Correct Answer is B
Explanation
Assess the client for the ability to ambulate independently. The highest priority nursing intervention for a client admitted to a neurologic rehabilitation unit following a cerebrovascular accident is to assess the client's ability to ambulate independently. This assessment will help the nurse determine the level of assistance required and develop an appropriate care plan.
Option A. Providing instruction on blood-thinning medication is not the highest priority as it can be done later when the client's ambulation status is stable.
Option C. Including the client in the planning of care and setting of goals is important but not the highest priority in this situation as it can be done after assessing the client's ambulation status.
Option D. Praise the client when using adaptive equipment, is not the highest priority as the client's ambulation status is more important at this point.
Correct Answer is D
Explanation
Diarrhea. A client who is recovering from bariatric surgery and is eating from a portable commode is at risk for diarrhea. Diarrhea can cause fluid and electrolyte imbalances, leading to dehydration, which can be life-threatening, especially in the immediate postoperative period.
Option A, impaired mobility, would not be a priority concern in the immediate postoperative period for this client.
Option B, impaired gas exchange, is not related to the situation.
Option C, self-care deficit, maybe a concern but is not as significant as diarrhea in the immediate postoperative period.
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