What is the best rationale for the following health care provider prescriptions for a client with a head injury: elevate the HOB: keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?
To prevent aspiration of stomach contents
To prevent flexion contractures
To decrease cerebral perfusion pressure
To avoid impeding venous outflow
The Correct Answer is D
A. To prevent aspiration of stomach contents: Elevating the head of the bed can help reduce aspiration risk, but in the context of a head injury, the primary concern is not gastrointestinal; this does not fully explain the combination of head and hip positioning.
B. To prevent flexion contractures: Avoiding sharp hip flexion helps prevent contractures, but the directive to maintain the head in neutral alignment is unrelated to musculoskeletal contracture prevention, so this does not encompass all prescribed measures.
C. To decrease cerebral perfusion pressure: Interventions like HOB elevation and neutral head position do not decrease cerebral perfusion pressure intentionally; the goal is to optimize cerebral blood flow while managing intracranial pressure, not to lower perfusion.
D. To avoid impeding venous outflow: Elevating the HOB, maintaining neutral head alignment, and avoiding sharp hip flexion prevent obstruction of venous return from the brain. This promotes cerebral venous drainage, reduces intracranial pressure, and helps prevent secondary brain injury, making it the primary rationale for these orders.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The apical pulse rate is 68 beats/minute: While propranolol lowers heart rate by blocking beta-adrenergic receptors, heart rate alone does not directly indicate prevention of variceal bleeding. The primary goal of therapy is to reduce portal hypertension and prevent hemorrhage.
B. Blood pressure is less than 120/80 mmHg: A reduction in blood pressure can occur with propranolol, but systemic blood pressure is not the most direct measure of efficacy in preventing esophageal variceal bleeding. Portal venous pressure reduction is the key therapeutic target.
C. Capillary refill is less than 2 seconds: Capillary refill reflects peripheral perfusion and is not related to the effectiveness of propranolol in controlling portal hypertension or preventing variceal hemorrhage.
D. Stools test negative for occult blood: The absence of occult blood in stools indicates that bleeding from esophageal varices is being prevented. This directly reflects the effectiveness of propranolol in reducing the risk of variceal hemorrhage, which is the primary therapeutic goal.
Correct Answer is D
Explanation
A. The client has likely developed a systemic infection: Systemic infections typically develop later in the course of burn injuries, often after the first 48–72 hours, and present with fever, tachycardia, and other systemic signs. While infection is a concern, it is less likely to explain acute airway obstruction at 36 hours post-burn.
B. The client is likely experiencing an anaphylactic reaction to a medication: Anaphylaxis usually occurs immediately or shortly after exposure to an allergen or new medication. The delayed development of airway obstruction 36 hours after burn injury makes anaphylaxis less likely.
C. The client's respiratory complications are likely related to psychosocial stress: Psychological stress can affect breathing patterns, but it does not cause physical airway obstruction or progressive respiratory compromise. The client’s airway changes are physiological rather than psychosocial in origin.
D. The client is likely experiencing a delayed onset of respiratory complications: Inhalation injuries can cause progressive airway edema that worsens hours after the initial burn. Swelling of the upper airway and bronchial mucosa can lead to obstruction, making this a delayed but serious respiratory complication that requires immediate intervention.
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