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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should use the term "postictal phase" when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.
Presence of absence seizures, presence of automatisms, and aura phase are not appropriate descriptions for the nurse to use when documenting this finding in the medical record. Absence seizures are a type of seizure characterized by brief episodes of staring and unresponsiveness. Automatisms are repetitive, unconscious movements that can occur during a seizure. The aura phase is a warning sign that can occur before a seizure.
Correct Answer is D
Explanation
The nurse should monitor the client for lethargy as a manifestation of increased intracranial pressure. Increased intracranial pressure (ICP) is a rise in pressure around the brain that can occur due to various reasons such as brain injury, bleeding into the brain, swelling in the brain, or an increase in cerebrospinal fluid. Lethargy (feeling less alert than usual) is a common symptom of increased ICP.
a. Nuchal rigidity is not a common symptom of increased ICP.
b. Batle's sign is not a common symptom of increased ICP.
c. Polyuria is not a common symptom of increased ICP.
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