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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Related Questions
Correct Answer is C
Explanation
When contributing to the plan of care for a client who is postoperative following a total hip arthroplasty, the nurse should include information on preventing hip flexion of the affected extremity. This can help prevent dislocation of the new hip joint and promote healing.
a. Positioning the lower extremities so that they are touching is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the lower extremities should be determined by the surgeon's instructions and the client's comfort.
b. Ensuring that the client's heels are touching the bed is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the heels should be determined by the surgeon's instructions and the client's comfort.
d. Instructing the client to avoid movement of the affected leg is not necessary for a client who is postoperative following a total hip arthroplasty. The client will need to begin moving and exercising the affected leg as part of their rehabilitation and recovery.
Correct Answer is C
Explanation
The nurse should anticipate that the provider will initially prescribe acetaminophen to the client who has a new diagnosis of osteoarthritis. Acetaminophen (Tylenol, others) has been shown to help some people with osteoarthritis who have mild to moderate pain². It is often used as a first-line treatment for osteoarthritis pain.
a. Hyaluronic acid is not typically the first medication prescribed for osteoarthritis.
b. Ibuprofen may be prescribed for osteoarthritis but is not typically the first medication prescribed.
d. Celecoxib may be prescribed for osteoarthritis but is not typically the first medication prescribed.
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