A nurse is caring for a 24-year-old female client who was admitted to the emergency unit following a horseback riding accident.
Increase the propofol infusion
Assess the client's pain
Notify the social worker the client is awake
Have the client sign consent forms for procedures already performed
Consider extubating the client
Determine the client’s decision-making ability
Decrease the noise and light stimuli in the room as much as possible
Explain all procedures
Correct Answer : B,F,G,H
Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.
Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.
Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.
Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.
Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.
Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.
Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.
Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A rationale
Paresthesia, or abnormal sensations such as tingling or numbness, is a common symptom of multiple sclerosis (MS) due to the demyelination of nerve fibers in the central nervous system. While it can be bothersome for the client, it is not typically an immediate life-threatening condition that requires urgent reporting to the healthcare provider. Ongoing management and monitoring of symptoms are important, but paresthesia alone does not necessitate immediate medical intervention.
Choice B rationale
Tremors are another common manifestation of MS, resulting from nerve damage that affects motor pathways. Tremors can significantly impact the client's quality of life, making daily activities challenging. However, like paresthesia, tremors are not usually considered an urgent condition that needs immediate reporting. They should be managed through a comprehensive care plan involving medications and physical therapy.
Choice C rationale
Tinnitus, or ringing in the ears, can occur in individuals with MS due to demyelination affecting the auditory pathways. While tinnitus can be distressing and affect the client's hearing, it is not typically an immediate life-threatening condition. It may require evaluation and symptomatic management, but it does not require urgent reporting unless it is associated with other severe symptoms.
Choice D rationale
Fever in a client with MS could indicate an infection or other inflammatory process, which can exacerbate MS symptoms and lead to a relapse. Fever may also signal a secondary complication such as a urinary tract infection or respiratory infection, which requires prompt medical attention. The healthcare provider should be notified immediately to evaluate and manage the underlying cause of the fever.
Choice E rationale
Tachycardia, or an abnormally rapid heart rate, can be a sign of several serious conditions, including infection, dehydration, or cardiovascular problems. In clients with MS, tachycardia may also indicate an autonomic dysfunction or be a response to fever or other stressors. Immediate reporting to the healthcare provider is necessary to determine the underlying cause and initiate appropriate treatment to prevent complications.
Correct Answer is ["A","D"]
Explanation
Choice A rationale: Oxygen saturation of 56% is critically low and indicates severe hypoxemia, which requires immediate intervention to improve oxygenation and prevent life-threatening complications.
Choice D rationale: Tracheal deviation to the right suggests a possible tension pneumothorax, which is a medical emergency. It requires immediate attention to relieve the pressure on the affected lung and restore normal breathing.
Choice B rationale: Crackles heard in the right lung indicate fluid or atelectasis but are not immediately life-threatening compared to the other findings.
Choice C rationale: A pH of 7.21 indicates acidemia and respiratory acidosis but is a secondary concern compared to the immediate need to address the client's hypoxemia and potential tension pneumothorax.
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