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^].
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Instructing the client to perform range-of-motion exercises to his lower extremities immediately after cardiac catheterization is not recommended. The client should maintain bed rest with the affected leg straight to prevent bleeding from the catheter insertion site.
Choice B reason: Ambulating the client 1 hour following the procedure is not advised. After femoral artery access, the client is typically required to remain on bed rest with the affected leg straight for several hours to ensure hemostasis and prevent bleeding².
Choice C reason: Restricting the client's fluid intake is not a standard post-procedure action. Adequate hydration is important after cardiac catheterization to help flush the contrast dye used during the procedure from the body, unless contraindicated.
Choice D reason: Assessing the color, temperature, and pulse in the affected extremity is crucial for detecting signs of bleeding, hematoma formation, or arterial occlusion. These assessments should be performed regularly as part of post-cardiac catheterization care².
Correct Answer is D
Explanation
Choice A reason: Tenderness in the left upper abdomen is not typically associated with an obstruction of the common bile duct. This symptom is more commonly related to conditions affecting the stomach, pancreas, or spleen. The common bile duct is in the right upper quadrant of the abdomen, and tenderness in this area might be expected with its obstruction.
Choice B reason: Ecchymosis of the extremities is not a common finding in common bile duct obstruction. Ecchymosis, or bruising, is usually due to trauma, blood disorders, or other causes of fragile blood vessels and is not related to bile duct issues.
Choice C reason: Pale-colored urine is the opposite of what might be expected with common bile duct obstruction. Typically, the urine may become dark due to increased bilirubin levels that are excreted by the kidneys when the bile duct is obstructed.
Choice D reason: Fatty stools, or steatorrhea, are a classic finding in common bile duct obstruction. When bile flow is blocked, fats are not properly digested and absorbed, leading to stools that are bulky, greasy, and often have a foul odor. This occurs because bile is necessary for the emulsification and absorption of dietary fats in the intestine.
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