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 C

Explanation

To prevent autonomic dysreﬂexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreﬂexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.

a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreﬂexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreﬂexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreﬂexia.

A. Remain with the client and call for help. B. Place the client in the lateral position C. Reorient and reassure the client. D. Check the client for injuries.

Correct Answer is A,B,D,C

Explanation

The correct sequence of steps the nurse should follow when a client begins to experience a tonic-clonic seizure is:

Remain with the client and call for help.
Place the client in the lateral position.
Check the client for injuries.
Reorient and reassure the client.

The nurse should first remain with the client and call for help to ensure that additional assistance is on the way. Next, the nurse should place the client in the lateral position to help keep their airway open and prevent aspiration. After the seizure has ended, the nurse should check the client for injuries that may have occurred during the seizure. Finally, the nurse should reorient and reassure the client, who may be confused or disoriented after the seizure.

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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 is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreﬂexia. Which of the following interventions should the nurse take to prevent autonomic dysreﬂexia?

Correct Answer is C

Explanation

Correct Answer is A,B,D,C

Explanation

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