A client sustained a head injury when hit by a lead pipe two hours ago and is admitted for observation after the computerized tomography (CT) scan indicates that no spinal cord injury and no skull fractures are present.
When the client begins projectile vomiting, the nurse quickly turns the client's head to the side and administers ondansetron 4 mg IV as prescribed.
Reassessment indicates that the client's Glasgow coma score is 13 and the left pupil is dilated without reaction to light.
Which intervention(s) should the nurse implement? Select all that apply.
Place in lateral Trendelenburg position.
Schedule a repeat CT scan.
Insert a second large bore IV catheter.
Apply artificial tear drops to the left eye.
Repeat Glasgow coma assessment.
Correct Answer : B,C,E
Choice A rationale
Placing a client with a head injury in the lateral Trendelenburg position is not recommended due to the risk of increasing intracranial pressure (ICP). This position can impede venous outflow from the brain, thereby exacerbating cerebral edema and ICP. Additionally, it can compromise the airway and lead to aspiration, especially in a client who is vomiting. Proper positioning, such as elevating the head of the bed to 30 degrees, is more appropriate to facilitate venous drainage and reduce ICP while protecting the airway. This choice is scientifically unsound and potentially harmful.
Choice B rationale
Scheduling a repeat CT scan is a critical intervention in this case. The client's condition has changed, evidenced by the onset of projectile vomiting and a dilated, non-reactive left pupil, both signs of potential increased ICP and possible brain herniation. A repeat CT scan will help identify any new or worsening intracranial pathology such as bleeding, swelling, or other changes that were not present initially. Timely imaging is essential for appropriate management and to guide further treatment decisions.
Choice C rationale
Inserting a second large bore IV catheter is vital for ensuring rapid access for fluids, medications, and possible blood products in the event of an acute deterioration. This is especially important in a neurologically unstable client. Having multiple IV access points allows for efficient administration of necessary treatments without delay, which can be crucial in managing worsening intracranial conditions and other emergent needs.
Choice D rationale
While applying artificial tear drops to the left eye might seem beneficial for preventing corneal dryness in a client who cannot blink, it does not address the acute neurological concerns indicated by the pupil changes and vomiting. This intervention is more supportive rather than urgent or diagnostic. The primary focus should be on identifying and managing the underlying cause of the client's deterioration, not on symptom management alone.
Choice E rationale
Repeating the Glasgow coma assessment is necessary to monitor any changes in the client's neurological status. Regular assessment helps track the progression or improvement of the client’s condition, guiding clinical decisions. The change in pupil response and vomiting suggests potential worsening, necessitating continuous and frequent reassessments. Prompt detection of deterioration can lead to quicker intervention and potentially better outcomes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale
Assisting the client to void before walking can prevent potential incontinence episodes, which might be embarrassing for the client. Additionally, a full bladder can increase the risk of falls due to discomfort or urgency to get to the restroom quickly.
Choice B rationale
While instructing the client about signs of orthostatic hypotension is important, it is not within the scope of practice for an unlicensed assistive personnel (UAP) to provide such instructions. This task falls under the responsibility of a licensed nurse.
Choice C rationale
Measuring the client's vital signs before walking helps to assess the client's baseline status and ensures that the client is stable enough to engage in physical activity. Any abnormal readings could indicate the need to postpone or modify the activity.
Choice D rationale
Reporting the onset of any dizziness or light-headedness is crucial for ensuring the client's safety during activity. These symptoms could indicate underlying issues such as orthostatic hypotension or other cardiovascular problems that need to be addressed promptly.
Choice E rationale
Determining if a gait belt is needed ensures that the client receives appropriate support while walking. A gait belt can provide additional stability and help prevent falls, especially for clients with limited tolerance for activity.
Correct Answer is A
Explanation
Choice A rationale
Donning appropriate personal protective equipment (PPE), including an N95 respirator mask, face shield, gown, gloves, and shoe coverings, is crucial to protect the nurse from potential exposure to the virus during close contact with a symptomatic client.
Choice B rationale
Teaching the client to wear a mask, hand wash, and maintain social distance is essential for preventing virus spread but is secondary to protecting the healthcare provider while collecting a test sample from a symptomatic client.
Choice C rationale
Informing the client to notify others about potential exposure is an important step in contact tracing, but it does not directly protect the nurse during the specimen collection procedure.
Choice D rationale
Notifying the charge nurse about the client's need for assignment to a COVID-19 designated area is important for appropriate care and isolation but does not directly address immediate protection for the nurse during the testing procedure.
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