A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

Intracranial pressure

Respiratory status

Temperature

Serum electrolytes

Answer and Explanation

The Correct Answer is B

A. Intracranial pressure: Monitoring intracranial pressure is important in clients with a history of subdural hematoma, but immediate assessment of respiratory status takes precedence in the immediate postoperative period to ensure adequate oxygenation and ventilation.

B. Respiratory status: Following evacuation of a subdural hematoma, the client may be at risk for respiratory compromise due to factors such as altered consciousness, impaired airway reflexes, or postoperative complications. Assessing respiratory rate, depth, oxygen saturation, and presence of respiratory distress is essential for early detection and intervention.

C. Temperature: Monitoring temperature is important for detecting signs of infection or systemic complications, but it is not the priority assessment immediately following evacuation of a subdural hematoma.

D. Serum electrolytes: While monitoring serum electrolytes is important for overall assessment and management of the client's condition, it is not the priority assessment in the immediate postoperative period following evacuation of a subdural hematoma.

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Correct Answer is D

Explanation

A. Therapeutic effects of medications may not be seen for 2-3 weeks: While it is important for the client to understand the timeline for therapeutic effects, ensuring medication adherence, especially during the initial period when therapeutic effects are not yet apparent, is of higher priority.
B. Physical dependency may result from extended use of medications: While the potential for physical dependency is an important consideration, ensuring medication compliance and adherence to the prescribed regimen, particularly in the context of managing seizures, takes precedence.
C. Urine may turn pink to brown but is not harmful: While this information may be included in the education plan to address potential side effects of antiepileptic medications, it is not the highest priority compared to ensuring the client understands the importance of taking medication regularly.
D. Take medication even if there is no seizure activity: Ensuring consistent medication adherence is crucial in managing seizure disorders to maintain therapeutic blood levels of antiepileptic medications and reduce the risk of breakthrough seizures. Missing doses can increase the risk of seizure recurrence.

A. "You may be able to prevent Bell's palsy by doing facial exercises regularly." B. "Medications to treat Bell's palsy work only if started before paralysis onset." C. "Call the doctor if you experience pain or develop herpes lesions near the ear." D. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy."

Correct Answer is C

Explanation

A. "You may be able to prevent Bell's palsy by doing facial exercises regularly." Regular facial exercises have not been proven to prevent Bell's palsy. In fact, excessive facial exercises could potentially exacerbate symptoms in some cases.

B. "Medications to treat Bell's palsy work only if started before paralysis onset." While early treatment with antiviral medications may be beneficial in some cases, it is not accurate to say that medications only work if started before paralysis onset. Treatment can still be effective even after the onset of symptoms, although it may not be as effective as when started early.

C. "Call the doctor if you experience pain or develop herpes lesions near the ear." This is important information because Bell's palsy has been associated with reactivation of the herpes simplex virus. Pain or the development of herpes lesions near the ear could indicate impending or active Bell's palsy, and prompt medical evaluation is necessary.

D. "Prophylactic treatment of herpes with antiviral agents prevents Bell's palsy." While antiviral medications can reduce the risk of herpes simplex virus reactivation, there is no guarantee that prophylactic treatment will prevent Bell's palsy. However, prompt treatment of herpes outbreaks may help reduce the risk.

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A nurse is caring for a client 4 hours following evacuation of a subdural hematoma. Which of the following assessments is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

Which of the following should be the highest priority of education plan for a client being treated with medication therapy for a generalized seizure disorder?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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