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 C

Explanation

Choice A reason: Occasional bubbling in the water-seal chamber can indicate an air leak, which is not necessarily a sign of lung re-expansion. It could suggest that the lung has not fully re-expanded or that there is a persistent air leak.

Choice B reason: While the absence of pleuritic chest pain is a positive sign, it is not a definitive indicator of lung re-expansion. Pleuritic chest pain can subside even if the lung has not fully re-expanded.

Choice C reason: No tidaling in the water-seal chamber is a strong indicator that the lung has re-expanded. When the lung is fully expanded, it presses against the chest wall, eliminating the space where air could collect and thus stopping the water level from fluctuating with respiration.

Choice D reason: An oxygen saturation of 95% is within normal limits and suggests adequate oxygenation, but it does not specifically indicate lung re-expansion. Oxygen saturation can be maintained with supplemental oxygen or other supportive measures even if the lung has not fully re-expanded.

A. Lower extremity edema B. Crackles in lung bases C. Jugular vein distention D. Ascites

Correct Answer is B

Explanation

Choice A reason:Lower extremity edema is more commonly associated with right-sided heart failure, as it indicates systemic fluid congestion.

Choice B reason:Crackles in lung bases are expected in left-sided heart failure due to pulmonary congestion from fluid backing up into the lungs².

Choice C reason:Jugular vein distention is typically a sign of right-sided heart failure, reflecting increased central venous pressure.

Choice D reason:Ascites, the accumulation of fluid in the peritoneal cavity, is generally associated with right-sided heart failure or liver disease, not specifically left-sided heart failure.

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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

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Correct Answer is B

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