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 C
Explanation
Wearing a lead apron can help protect the nurse from radiation exposure while providing care to a client receiving internal radiation therapy.
Choice A is incorrect because visitors may need to limit their contact with the client and follow specific safety precautions.
Choice B is incorrect because a dosimeter film badge is worn by the nurse to measure radiation exposure, not placed on the client’s door.
Choice D is incorrect because the door to the client’s room may need to be kept closed as a safety precaution 2.
Correct Answer is D
Explanation
The correct answer isChoice D.
Choice A rationale:Checking potassium levels is important in the management of DKA, but it is not the priority intervention.The priority intervention is to restore intravascular volume with fluid resuscitation
Choice B rationale:Bicarbonate infusion is not the priority intervention in the management of DKA.It is used only in severe cases of metabolic acidosis
Choice C rationale:Initiation of a continuous IV insulin infusion is an important intervention in the management of DKA, but it is not the priority intervention.The priority intervention is to restore intravascular volume with fluid resuscitation
Choice D rationale:Administering 0.9% sodium chloride is the priority intervention in the management of DKA.It is used to restore intravascular volume and correct electrolyte imbalances
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