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.
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Correct Answer is B
Explanation
The correct answer is B.
Assist the adolescent in applying for Medicaid.
This action demonstrates the nurse’s role as an advocate and a resource person for the client, who might be eligible for financial assistance and health care coverage during her pregnancy and postpartum period. Medicaid is a federal and state program that provides health insurance for low-income individuals and families.
Choice A is wrong because contacting the adolescent’s parent for assistance might violate the client’s confidentiality and autonomy, especially if the parent is not aware of or supportive of the pregnancy. The nurse should respect the client’s right to privacy and self-determination, unless there is a risk of harm to the client or the fetus.
Choice C is wrong because referring the adolescent to a local mental health clinic might imply that the client has a mental disorder or needs psychological counseling, which could be stigmatizing and discouraging.
The nurse should assess the client’s emotional state and coping skills, and provide supportive and nonjudgmental care. The nurse can also offer referrals to other community resources, such as prenatal education, parenting classes, or social services, that might benefit the client.
Choice D is wrong because advising the adolescent to place the newborn for adoption might interfere with the client’s decision-making process and personal values.
The nurse should not impose his or her own opinions or beliefs on the client, but rather explore the client’s feelings and preferences about her pregnancy options. The nurse should provide factual information and education about adoption, abortion, or parenting, and help the client weigh the benefits and risks of each option.
Correct Answer is D
Explanation
A. BP 150/92 mm Hg:
- This blood pressure reading is elevated and not a therapeutic effect of magnesium sulfate. In the context of preeclampsia, the goal is usually to lower blood pressure to prevent complications.
B. Pulse rate 100/min:
- The pulse rate of 100/min is not a specific therapeutic effect of magnesium sulfate. However, magnesium sulfate may cause a decrease in heart rate, so monitoring for bradycardia would be important.
C. Flushed face:
- A flushed face is not a specific therapeutic effect of magnesium sulfate. Facial flushing may be associated with other factors, but it is not a primary consideration when monitoring the effectiveness of magnesium sulfate in the context of preeclampsia.
D. Negative clonus:
- Negative clonus is the correct therapeutic effect to monitor. Clonus refers to a series of involuntary, rhythmic, and repetitive muscle contractions and relaxations. In the context of magnesium sulfate administration for preeclampsia, negative clonus (the absence of abnormal reflexes) is a sign that the magnesium levels are within the therapeutic range, helping to prevent seizures.
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