A nurse is assessing a client who has suffered a traumatic brain injury. When the nurse applies a stimuli to the client, which of the following responses by the client indicates that the client has suffered an extensive cervical spine injury?

Choice A reason: This is incorrect because education about mastoidectomy is not relevant for a client with an upper respiratory infection. Mastoidectomy is a surgical procedure that removes part or all of the mastoid bone behind the ear, which can become infected or inflamed due to chronic or recurrent middle ear infections. The nurse should assess
the client's ear for signs of mastoiditis, such as swelling, tenderness, or redness behind the ear, but mastoidectomy is not a common or first-line treatment for upper respiratory infection.
Choice B reason: This is incorrect because a referral for a hearing test is not necessary for a client with an upper respiratory infection. Hearing test is a diagnostic tool that measures how well a person can hear different sounds at different frequencies and intensities. The nurse should ask the client about any changes in hearing or tinnitus, which are possible complications of upper respiratory infection, but a hearing test is not a routine or urgent intervention for this condition.
Choice C reason: This is correct because education on the administration of oral antibiotics can help treat an upper respiratory infection. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Upper respiratory infections can be caused by various pathogens, such as viruses, bacteria, or fungi, but bacterial infections are more likely to cause fever, otalgia, or purulent nasal drainage. The nurse should instruct the client on how to take antibiotics as prescribed, such as dosage, frequency, duration, side effects, and interactions.
Choice D reason: This is incorrect because a prescription for an antifungal cream is not appropriate for a client with an upper respiratory infection. Antifungal cream is a topical medication that kills or inhibits fungi that cause skin infections. Upper respiratory infection is not a skin infection, but an infection of the nose, throat, or sinuses. Antifungal cream has no effect on upper respiratory infection and may cause adverse effects or resistance.

The total fluid prescribed is 5,200 mL over 24 hours. We need to calculate how much fluid the client will receive in the first 8 hours.

Step-by-Step Calculation:

Step 1: Determine how much fluid is given in the first 8 hours. The rule is that half of the total fluid is administered in the first 8 hours.

• Total fluid = 5,200 mL.
• Fluid for the first 8 hours = Total fluid ÷ 2.

Write it out:
5,200 ÷ 2 = 2,600.

Result: 2,600 mL.