A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

Administer opioids.

Apply restraints.

Reduce stimuli.

Blacken the room.

Answer and Explanation

The Correct Answer is C

An appropriate nursing action for a client who is restless following a traumatic brain injury with increased intracranial pressure is to reduce stimuli. This can help calm the client and prevent further increases in intracranial pressure. The nurse can reduce stimuli by minimizing noise and light in the client's environment and limiting the number of visitors.

Administering opioids, applying restraints, and blackening the room are not appropriate nursing actions for this situation. Administering opioids can cause respiratory depression and is not recommended for clients with increased intracranial pressure. Applying restraints can increase agitation and is not recommended for clients who are restless. Blackening the room can disorient the client and is not recommended.

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Correct Answer is A

Explanation

The first action the nurse should take is to check the client for injuries. The nurse should assess the client for any signs of injury or trauma and provide appropriate care as needed.

Obtaining a prescription for medication to sedate the client, calling the family and asking them to make arrangements for someone to sit with the client, and assisting the client back into bed and applying restraints are not appropriate initial actions for the nurse to take in this situation. These actions may be considered after the client has been assessed for injuries and their immediate needs have been addressed.

A. The weights rest against the foot of the bed. B. The ropes are in the center of the wheel grooves. C. The weights are equal on each side. D. The ropes atach securely to the pin

Correct Answer is A

Explanation

If a client returns to the surgical unit from the PACU in skeletal traction and the weights rest against the foot of the bed, the nurse should take action to correct this problem with the traction setup. The weights should be hanging freely and not touching any part of the bed or ﬂoor. This ensures that the traction is providing the appropriate amount of force to the aﬀected limb.

The other options listed are not problems with the traction setup. The ropes should be in the center of the wheel grooves, the weights should be equal on each side, and the ropes should attach securely to the pin.

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A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility finds an older adult client lying on the ﬂoor next to the bed. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A client returns to the surgical unit from the PACU in skeletal traction. The nurses should take action to correct. Which of the following problems with the traction setup?

Correct Answer is A

Explanation

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