A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?
Prepare the client for an MRl of the brain.
Administer mannitol IV bolus to the client.
Determine the client's Glasgow Coma Scale score.
D insert an indwelling urinary catheter for the client.
The Correct Answer is C
The correct answer is choice C. Determine the client’s Glasgow Coma Scale score. This is because the Glasgow Coma Scale (GCS) is a tool to assess the level of consciousness and neurological status of a client who has a closed head injury. The GCS score can help guide the priority of interventions and the need for further diagnostic tests.
Choice A is wrong because an MRI of the brain is not the first action to take for a client who has a closed head injury. An MRI may be indicated later to evaluate the extent of brain damage, but it is not an emergency procedure.
Choice B is wrong because mannitol IV bolus is a medication that reduces intracranial pressure (ICP) by drawing fluid out of the brain tissue. However, mannitol should not be administered before confirming the presence and degree of increased ICP, which can be done by measuring the GCS score and other vital signs.
Choice D is wrong because inserting an indwelling urinary catheter for the client is not the first action to take for a client who has a closed head injury. A urinary catheter may be needed to monitor fluid balance and renal function, but it is not an urgent intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. Apply direct pressure to the puncture site.
Choice A rationale:
Applying intermittent pressure 2.5 cm (1 inch) below the percutaneous skin site is not the best approach. This method may not effectively control the bleeding and could potentially dislodge the introducer sheath.
Choice B rationale:
Applying direct pressure to the puncture site is the most effective way to control bleeding. Direct pressure helps to promote clot formation and reduce blood flow to the area, which is crucial in managing postoperative bleeding.
Choice C rationale:
Elevating the affected extremity above the level of the heart is not appropriate in this situation. While elevation can reduce swelling, it does not address the immediate need to control active bleeding.
Choice D rationale:
Leaving the dressing undisturbed and notifying the physician immediately is not advisable. Immediate action to control the bleeding is necessary before notifying the physician. Delaying intervention could lead to significant blood loss.
Correct Answer is B
Explanation
The correct answer is choice B. Fish. Fish is a good source of protein and omega-3 fatty acids, which can help lower blood pressure, reduce inflammation, and prevent blood clots. Fish is also low in sodium, which is important for people with hypertension, as excess sodium can raise blood pressure by retaining fluid in the body. Fish is part of the DASH diet, which stands for Dietary Approaches to Stop Hypertension, and is a healthy eating plan that emphasizes fruits, vegetables, whole grains, low-fat dairy, nuts, seeds, legumes, and lean meats.
Choice A. Cheese is wrong because cheese is high in sodium and saturated fat, which can increase blood pressure and cholesterol levels.
Cheese should be limited or avoided by people with hypertension.
Choice C. Red meat is wrong because red meat is also high in sodium and saturated fat, as well as cholesterol, which can contribute to hypertension and heart disease.
Red meat should be eaten sparingly or replaced by leaner sources of protein like fish, poultry, or beans.
Choice D. Canned black beans are wrong because canned black beans are high in sodium, as most canned foods are preserved with salt. Canned black beans should be rinsed well before eating or replaced by dried or cooked black beans, which are lower in sodium and high in fiber, potassium, magnesium, and calcium, which are beneficial for blood pressure control.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.