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","B","C","D"]
No explanation
Correct Answer is ["B","F","G","H"]
Explanation
Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.
Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.
Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.
Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.
Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.
Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.
Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.
Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.
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