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 B

Explanation

Choice A reason:Bubbling in the water seal chamber with exhalation can be normal, indicating that air is being evacuated from the pleural space.

Choice B reason:Crepitus, or subcutaneous emphysema, can indicate that air is leaking into the tissue around the chest tube site, which is a serious complication that requires immediate attention.

Choice C reason:

Movement of the trachea toward the unaffected side can indicate tension pneumothorax, a life-threatening condition that also requires immediate attention.

Choice D reason:If the eyelets of the chest tube are not visible, it may simply mean that the tube is inserted fully, which is not an immediate cause for concern unless other symptoms are present.

A. Asterixis B. Change in orientation C. Anorexia D. Ascites E. Fetor hepaticus

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

Explanation

Choice A reason: Asterixis, also known as "liver flap," is a tremor of the hand when the wrist is extended, often seen in hepatic encephalopathy as a result of altered brain function.

Choice B reason: A change in orientation, including confusion and altered consciousness, is a hallmark of hepatic encephalopathy, reflecting the brain's impaired ability to process information.

Choice C reason: Anorexia may be present in cirrhosis, but it is not a specific indicator of hepatic encephalopathy.

Choice D reason: Ascites is a common complication of cirrhosis due to portal hypertension but is not a direct indicator of hepatic encephalopathy.

Choice E reason: Fetor hepaticus, a musty odor of the breath, is a distinctive symptom of hepatic encephalopathy caused by the presence of mercaptans in the breath as the liver fails to break down sulfur-containing amino acids.

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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 assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider immediately?

Correct Answer is B

Explanation

A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).

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

Explanation

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