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A nurse is caring for a client on a medical-surgical unit

Exhibits

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

as evidenced by the client's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Option 1: Intracranial hemorrhage: The client’s recent fall, worsening headache, unilateral pupil dilation, right-sided weakness, and decreasing Glasgow Coma Scale (GCS) indicate a potential neurological injury, which is concerning for intracranial hemorrhage.

Option 2: Glasgow Coma Scale: The client's GCS has progressively declined (from 15 to 13), indicating a decrease in neurological function, which is critical in assessing intracranial pressure and risk for hemorrhage.


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Related Questions

Correct Answer is A

Explanation

A. Sleeping on the left side can reduce acid reflux symptoms because it keeps the stomach below the esophagus, potentially preventing stomach acid from entering the esophagus.

B. Waiting only 1 hour after eating may not be enough; generally, clients with GERD are advised to wait at least 2-3 hours before lying down.

C. Eating four small meals each day may not be sufficient; GERD patients are often advised to eat smaller, more frequent meals to reduce stomach pressure and prevent reflux.

D. Drinking milk may temporarily soothe the stomach but can stimulate acid production and worsen GERD symptoms over time.

Correct Answer is D

Explanation

A.This is generally avoided after a total knee replacement. Specifically, placing a pillow under the knee (popliteal space) can cause a flexion contracture, where the knee becomes stuckin a bent position. The goal is to keep the knee extended as much as possible.

B. Applying cool compresses every 6 hours is not typically recommended postoperatively, as frequent, direct cooling could impede blood flow to the surgical area.

C. Promoting bed rest for 5-7 days is not advised; early mobility is encouraged to prevent complications such as deep vein thrombosis and improve joint function.

D.In the immediate postoperative period, increasing fluid intake helps maintain hydration, compensates for blood loss during surgery, and assists in the excretion of anesthetic agents. It also helps prevent complications like urinary tract infections and constipation, which can occur due to immobility and opioid pain medications.

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