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 B
Explanation
- A. "You should ask your provider about your plan." This response is appropriate because it acknowledges the client's desire to explore alternative treatments while directing them to the appropriate source for medical advice. It promotes client autonomy and ensures they receive accurate information from their healthcare provider.
- B. "Tell me what you know about chemotherapy." This response is also appropriate. It encourages the client to express their understanding and concerns about chemotherapy, allowing the nurse to identify any misconceptions and provide accurate information. This also opens the door for the client to express their concerns about vitamins and minerals, and why they want to persue that treatment.
- C. "I have never heard of any holistic treatment that is effective." This response is inappropriate because it dismisses the client's preferences and demonstrates a lack of respect for their autonomy. It also displays a lack of knowledge, as some holistic treatments can be used as supportive therapies.
- D. "The best way to treat your cancer is chemotherapy." This response is inappropriate because it is directive and does not allow the client to participate in decision-making. It also does not address the client's desire to explore alternative treatments.
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.
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