A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?

Place a cool cloth on the forehead.

Elevate the head of the bed 30 degrees.

Administer morphine 2 mg IV.

Prepare for a lumbar puncture.

Answer and Explanation

The Correct Answer is B

Choice A reason:Placing a cool cloth on the forehead may provide comfort but does not address intracranial pressure, which could be causing the headache[^10^].

Choice B reason:Elevating the head of the bed 30 degrees helps to decrease intracranial pressure and can alleviate headache symptoms associated with a closed head injury[^10^].

Choice C reason:Administering morphine for pain relief should be done with caution, as it can depress respiration and mask changes in the level of consciousness, which are important indicators of neurological status[^10^].

Choice D reason:A lumbar puncture is contraindicated in the presence of increased intracranial pressure due to the risk of brain herniation[^10^].

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Asterixis, also known as “liver flap,” is a type of tremor characterized by rapid, nonrhythmic extensions and flexions in the wrist and fingers. It is associated with hepatic encephalopathy, a condition that can occur with severe liver disease, but it is not a direct indicator of low albumin levels.

Choice B reason: Peripheral edema is a common clinical finding in patients with hypoalbuminemia, which is a low level of albumin in the blood. When albumin levels are low, fluid from the bloodstream can leak into body tissues, causing swelling, especially in the lower limbs. When assessing a client with liver disease and low albumin levels, palpating for peripheral edema would be the most relevant nursing assessment, as it directly correlates with the effects of hypoalbuminemia on fluid balance in the body. Albumin is a protein made by the liver that helps keep fluid in your blood vessels and plays a role in transporting substances throughout your body. Low levels of albumin can lead to fluid leaking out of blood vessels into tissues, causing swelling or edema.

Choice C reason: Decreased level of consciousness can be a sign of various conditions, including hepatic encephalopathy or other complications of liver disease, but it is not specifically indicative of low albumin levels.

Choice D reason: Petechiae are small red or purple spots caused by bleeding into the skin and may be associated with various conditions, including liver disease, but they are not a specific sign of low albumin levels.

A. Administer antiemetics as needed. B. Administer analgesics as needed. C. NPO (nothing by mouth) until pain-free. D. Monitor blood glucose and provide insulin as needed. E. Side-lying or fetal position. F. Monitor hydration status.

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

Explanation

Choice A: Administer antiemetics as needed Reason: Acute pancreatitis often causes severe nausea and vomiting. Antiemetics are administered to control these symptoms and prevent further complications such as dehydration and electrolyte imbalance.

Choice B: Administer analgesics as needed Reason: Pain management is a crucial part of the treatment for acute pancreatitis. The condition can cause severe abdominal pain, and analgesics are administered to provide relief.

Choice C: NPO (nothing by mouth) until pain-free Reason: The goal in treating acute pancreatitis is to allow the pancreas to rest and recover from the inflammation3. Keeping the patient NPO (nothing by mouth) helps achieve this by reducing the stimulation and workload of the pancreas.

Choice D: Monitor blood glucose and provide insulin as needed Reason: Acute pancreatitis can affect the pancreas’ ability to produce insulin, leading to elevated blood glucose levels. Therefore, monitoring blood glucose levels and administering insulin as needed is an important part of the management plan.

Choice E: Side-lying or fetal position Reason: While the side-lying or fetal position might help some patients with abdominal pain, it is not a standard intervention for acute pancreatitis. Therefore, this option is not correct.

Choice F: Monitor hydration status Reason: Patients with acute pancreatitis are at risk of dehydration due to symptoms like vomiting and decreased oral intake. Monitoring hydration status is crucial to ensure appropriate fluid replacement.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client who has a recent closed head injury reports a severe headache and is restless. Which of the following is an appropriate nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing laboratory test results for the client with liver disease and notes that the client's albumin level is low. Which nursing assessment indicates low albumin levels?

Correct Answer is B

Explanation

A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).

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

Explanation

A nurse is caring for a client who has cirrhosis of the liver. Which of the following medications should the nurse anticipate may be ordered for this client? (Select all that apply.)

A nurse is obtaining a health history for a client with chronic pancreatitis. Which of the following indicates the primary cause of the client's condition?

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease (CKD). Which of the following findings should the nurse expect?

A client with a history of angina is being admitted to the emergency department with a suspected myocardial infarction (MI). Which of the following findings will help the nurse distinguish stable angina from an MI?

A nurse admits a client to the emergency department who reports nausea, vomiting, and epigastric pain that worsens when lying down. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?

The healthcare provider prescribes lactulose for a patient with hepatic encephalopathy. What will the nurse assess to determine the effectiveness of this medication?

A nurse is caring for a client who has valvular heart disease and is at risk for developing left-sided heart failure. Which of the following manifestations should alert the nurse that the client is developing this condition?

A client is admitted to the emergency department after sustaining multiple rib fractures in a motor vehicle accident. Upon assessment, the nurse notes that the client has flail chest. Which of the following signs and symptoms are associated with this condition? (Select all that apply.)