22. A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Establish IV access.

Open the airway using a jaw-thrust maneuver.

Remove clothing for a thorough assessment.

Perform a Glasgow Coma Scale assessment..

Determine effectiveness of ventilator efforts.

Answer and Explanation

The Correct Answer is B, E, A, D, C

B. The first priority in a primary survey is to open and maintain the airway; in a trauma client, this is done with a jaw-thrust maneuver to protect the cervical spine. E. After the airway is established, the nurse should assess breathing and determine the effectiveness of ventilatory efforts. A. Once airway and breathing are stabilized, circulation is addressed by establishing IV access for fluid or blood administration. D. Disability is assessed next using tools such as the Glasgow Coma Scale to evaluate neurologic status. C. Exposure is the final step; the nurse removes clothing to perform a thorough assessment while preventing hypothermia.

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Correct Answer is C

Explanation

A. Administer naproxen: While pain management is important, naproxen may not effectively resolve the headache associated with post-lumbar puncture headache (PLPH), which is often caused by cerebrospinal fluid leakage.

B. Elevate the head of the bed to 30°: While elevating the head of the bed may provide some relief, it is not typically sufficient to resolve PLPH, which often requires more definitive interventions.

C. Check BP and call for a blood patch: PLPH is commonly treated with a blood patch, which involves injecting the patient's own blood into the epidural space to seal the puncture site and restore normal cerebrospinal fluid pressure. Checking blood pressure is important to assess for hypotension, and calling for a blood patch is the most appropriate action to address the underlying cause of the headache.

D. Darken the client's room and close the door: While creating a quiet and dim environment may help alleviate symptoms of headache, it does not address the underlying cause of PLPH and is not the most appropriate intervention in this situation.

A. Hyperthermia B. Weakened gag reflex C. Absence of bowel sounds D. Hypotension E. Polyuria

Correct Answer is ["B","D"]

Explanation

A. Slurred speech: This can be a sign of increased ICP but is not typically considered a late sign. It is more often associated with early or moderate increases in ICP when the brain is starting to experience pressure but is not yet at a critical stage.
B. Bradycardia: This is a late sign of increased ICP and is part of Cushing's triad, which includes bradycardia, irregular respirations, and a widened pulse pressure. Bradycardia occurs as a compensatory mechanism to decrease the cerebral blood flow in response to increased ICP.
C. Hypotension: While changes in blood pressure can be associated with ICP, hypotension is not typically a late sign of increased ICP. In fact, hypertension with a widened pulse pressure would be more indicative of increased ICP as part of Cushing's triad.
D. Nonreactive dilated pupils: This is a late sign of increased ICP and indicates brain stem herniation or compression, which is a medical emergency. The pupils become fixed and dilated as the oculomotor nerve is compressed due to increased pressure.
E. Confusion: Confusion can be an early sign of increased ICP as it indicates changes in mental status. However, it is not specifically a late sign of increased ICP, as it can occur at various stages of pressure changes within the brain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who reports a throbbing headache and hypotension after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Correct Answer is C

Explanation

A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is caring for a 24-year-old client who reports a recent fall, hitting their head and right shoulder. Exhibits Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown

A nurse is creating a plan of care for a client who has a history of tonic-clonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

What will the nurse tell the patient who has cerebral atherosclerosis about taking clopidogrel?

A nurse is caring for a client who has an intracranial aneurysm and requires aneurysm precautions. Which of the following interventions should the nurse take?

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-year-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?

Which intervention should the nurse include in the plan of care for a patient with new right- sided homonymous hemianopsia after a stroke?

Which information about the patient who had a subarachnoid hemorrhage is most important to communicate to the health care provider?