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
Platelets 70,000/mm.
The priority finding for a nurse assessing a client who has cirrhosis to report is a platelet count of 70,000/mm.
A low platelet count (thrombocytopenia) can be a complication of cirrhosis and can increase the risk of bleeding.
A platelet count below 150,000/mm3 is considered low and should be reported to the provider.
Choice A is incorrect because while a distended abdomen can be a sign of ascites, a complication of cirrhosis, it is not the priority finding to report.
Choice B is incorrect because while clay-colored stools can be a sign of biliary obstruction, it is not the priority finding to report.
Choice D is incorrect because while an elevated alkaline phosphatase level can be a sign of liver damage, it is not the priority finding to report.
Correct Answer is B
Explanation
This statement indicates that the client understands that genital herpes lesions can take time to heal and that they may not resolve immediately.
Choice A is incorrect because antibiotic ointment is not used to treat genital herpes lesions.
Antiviral medication is used to manage symptoms and prevent outbreaks.
Choice C is incorrect because natural skin condoms are not effective in preventing the spread of genital herpes.
Latex condoms should be used during sexual intercourse to reduce the risk of transmission.
Choice D is incorrect because the duration of antiviral medication treatment for genital herpes varies and may be longer than 3 weeks.
It’s important for the client to follow their healthcare provider’s instructions for taking medication.
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