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.
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Related Questions
Correct Answer is B
Explanation
The nurse should attend to the client who has thrombocytopenia and reports a nosebleed first.
Thrombocytopenia is a condition characterized by low platelet count, which increases the risk of bleeding.
A nosebleed can be a sign of significant bleeding, and it is important for the nurse to assess the severity and take appropriate action to stop the bleeding and prevent further complications.
Although the other clients also require nursing care, their conditions are not as urgent as the client with thrombocytopenia and a nosebleed.
The client with chronic obstructive pulmonary disease and an oxygen saturation of 89% may require oxygen therapy or other interventions to improve respiratory function, but the situation is not immediately life-threatening.
The client with left-sided paralysis and slurred speech from a prior stroke may require ongoing care and rehabilitation, but there is no indication of an acute change in their condition.
The client with multiple sclerosis and ataxia and vertigo may require assistance with mobility and balance, but their symptoms do not pose an immediate threat to their health.
Correct Answer is D
Explanation
The nurse should ask the client to empty his bladder prior to the procedure.
This is important because a full bladder can obstruct the area where the needle will be inserted and increase the risk of bladder injury during the procedure.
Choice A is incorrect because the client should be positioned sitting upright or lying in bed with the head of the bed elevated during the procedure.
Choice B is incorrect because administering a stool softener is not necessary following an abdominal paracentesis.
Choice C is incorrect because the client should be instructed to exhale and hold their breath during needle insertion to help move the diaphragm upward and away from the area where the needle will be inserted.
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