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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Aspiration is a common complication in patients with dysphagia post-stroke due to impaired swallowing reflexes, leading to food or liquid entering the lungs.
Choice B reason: Gastroesophageal reflux disease could be a concern but is not directly related to dysphagia post-stroke.
Choice C reason: Peptic ulcer disease is not typically a complication of dysphagia post-stroke.
Choice D reason: Dumping syndrome is related to rapid gastric emptying post-meal, not dysphagia post-stroke.
Correct Answer is A
Explanation
Choice A reason:Using a microwave to warm the solution is not recommended as it can lead to uneven heating and potentially damage the solution or harm the patient.
Choice B reason: The statement about the catheter becoming infected despite sterile precautions is accurate and reflects an understanding of the risks associated with peritoneal dialysis.
Choice C reason:Expecting the volume of the output solution to be greater than the input solution is incorrect; typically, the volumes should be equal to ensure proper fluid removal.
Choice D reason: The fluid from the abdomen being clear or slightly yellow is a normal finding and does not indicate a need for further teaching.
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