A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless.
Which of the following assessments should the nurse perform first?
Motor responses.
Blood glucose.
Urinary output.
Blood pressure.
The Correct Answer is D
A change in behavior such as agitation and restlessness in a client with a traumatic brain injury can be a sign of increased intracranial pressure.
The nurse should first assess the client’s blood pressure as an increase in blood pressure can be an indicator of increased intracranial pressure.
Motor responses are not the first assessment that should be performed.
Blood glucose is not the first assessment that should be performed.
Urinary output is not the first assessment that should be performed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement indicates an understanding of the teaching because headache is a common symptom of anemia.
Choice B is incorrect because bradycardia (slow heart rate) is not a common symptom of anemia.
Instead, anemia can cause irregular heartbeats or a fast heartbeat.
Choice Dis incorrect because flushed skin color is not a common symptom of anemia.
Instead, anemia can cause pale or yellowish skin 1.
Choice Cis incorrect because heat intolerance is not a common symptom of anemia.
Correct Answer is D
Explanation
Monitor the client for adequate urine output.
When administering potassium chloride via IV infusion to a client who has severe hypokalemia, it is important for the nurse to monitor the client’s urine output to ensure that their kidneys are functioning properly and that they are able to excrete excess potassium.
Choice A is incorrect because the infusion site should be checked more frequently than every 4 hours.
Choice B is incorrect because the maximum recommended rate of infusion for potassium chloride is 10 mEq/hr.
Choice C is incorrect because Chvostek’s sign is used to assess for hypocalcemia, not hypokalemia.
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