A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?
Monitor the client's electrolyte levels.
Suction saliva from the client's mouth.
Perform passive range of motion on each extremity.
Record the client's intake and output.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
No explanation
Correct Answer is A
Explanation
A.Correct. Increasing fluid intake can help replenish cerebrospinal fluid (CSF) that was lost during the lumbar puncture, which can reduce the pressure difference between the brain and spinal cord that causes the headache.
B.Incorrect. Administering pain medication can help relieve the headache temporarily, but it does not address the underlying cause of CSF loss and pressure difference.
C. Incorrect. Darkening the client's room and closing the door can help reduce sensory stimuli that may aggravate the headache, but it does not address the underlying cause of CSF loss and pressure difference.
D. Incorrect. Elevating the head of the bed to 30 can worsen the headache by increasing the pressure difference between the brain and spinal cord, as gravity pulls more CSF away from the brain.
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