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
Choice A reason:Providing oral care every 4 hours and as needed is an evidence-based practice to lower the risk of ventilator-associated pneumonia by minimizing the buildup of bacteria in the mouth³.
Choice B reason:Positioning the head of the client's bed in the flat position is not recommended as it can increase the risk of aspiration; elevating the head of the bed to 30° to 45° is the standard practice.
Choice C reason:Turning the client every 4 hours is important for preventing pressure ulcers and improving lung function but is not the primary action for reducing pneumonia risk³.
Choice D reason:Providing humidity helps to maintain mucous membrane integrity but must be carefully managed to prevent bacterial growth and is not the primary action for reducing pneumonia risk³.
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.
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