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^].

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Correct Answer is A

Explanation

Choice A reason: Disequilibrium syndrome is characterized by headache, nausea, and agitation, which can occur during or after hemodialysis, especially in the first few sessions as the body adjusts to the treatment².

Choice B reason: Septicemia would typically present with fever, chills, and hypotension, not specifically headache and agitation².

Choice C reason: Air embolism is a rare complication that would present with sudden respiratory distress, chest pain, and possibly hypotension, not just headache and agitation².

Choice D reason: Peritonitis is associated with abdominal pain and tenderness, fever, and possibly altered bowel movements, not the symptoms described².

A. Severe fluid and electrolyte imbalance B. Upper abdominal distention C. Metabolic acidosis D. Projectile vomiting with a fecal odor E. Diarrhea or ribbon-like stools

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

No explanation

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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

A nurse is caring for a client during his first hemodialysis treatment. The client reports a headache, nausea, and is agitated. Which of the following complications should the nurse identify these findings as manifestations of?

Correct Answer is A

Explanation

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

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