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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","C","D"]

Explanation

The correct answers are Choices A, C, and D.

Choice A rationale: Encouraging the client to increase physical activity and engage with peers is appropriate as it helps prevent deconditioning, improves cardiovascular health, and promotes mental well-being. Physical activity can also improve muscle strength, mobility, and overall quality of life.

Choice B rationale: Suggesting the client remain in bed to avoid unnecessary exertion is incorrect. Prolonged bed rest can lead to muscle atrophy, pressure injuries, and decreased cardiovascular function. The client should be encouraged to mobilize as tolerated to maintain functional abilities.

Choice C rationale: Teaching the caregiver how to monitor for signs of infection in pressure injuries is crucial because the client has stage II pressure injuries that need careful monitoring and management to prevent complications such as infection. Education on signs of infection, proper wound care, and prevention strategies is essential.

Choice D rationale: Assisting the client in using the restroom to avoid incontinence is appropriate as it respects the client's preference for toileting, reduces the risk of skin breakdown, and promotes dignity. Helping the client maintain continence and proper hygiene is important for comfort and overall health.

A. Crush to increase absorption. B. Take before bedtime. C. Administer with a meal. D. Store at room temperature.

Correct Answer is B

Explanation

Choice A rationale

Crushing zolpidem to increase absorption is inappropriate because it is a controlled-release medication. Crushing the tablet would disrupt the controlled-release mechanism, leading to rapid absorption, increased side effects, and potentially dangerous consequences.

Choice B rationale

Taking zolpidem before bedtime is correct because it is a medication prescribed for insomnia. It helps the patient fall asleep more quickly by acting on the central nervous system to induce sleep, and it should be taken when the patient is ready to sleep.

Choice C rationale

Administering zolpidem with a meal is not recommended. Food can delay the absorption of the medication, reducing its effectiveness in helping the patient fall asleep promptly.

Choice D rationale

Storing zolpidem at room temperature is correct, but it is not a critical point of patient education. The emphasis should be on taking the medication as prescribed and understanding its purpose and potential side effects.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C","D"]

Explanation

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

Correct Answer is B

Explanation

Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's plan of care?

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

A client expresses concern about receiving proper care in accordance with the client's religion. Which action is best for the nurse to take?

A nurse is caring for an 84-year-old female client in her home to establish home health care and perform an initial assessment. Exhibits Which intervention(s) should the nurse initiate if elder mistreatment is suspected? Select all that apply.

Exhibits The nurse is reviewing the client's data. Which of the following findings should the nurse report to the primary health care provider immediately? Select all that apply.