A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash. For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?
The client has a delayed response to verbal commands.
The client has ecchymosis around the eyes.
The client is unable to remember details of the motor-vehicle crash.
The client reports ringing in the ears.
The Correct Answer is A
Choice A Reason:
The client has a delayed response to verbal commands. This finding can indicate increased intracranial pressure. Changes in responsiveness, such as delayed responses to verbal commands or other stimuli, can be indicative of neurological impairment due to elevated pressure within the skull.
Choice B Reason:
The client has ecchymosis around the eyes. Ecchymosis around the eyes (raccoon eyes) can occur with certain head injuries, but it's not a direct sign of increased intracranial pressure. It's more commonly associated with basilar skull fractures rather than specifically reflecting increased pressure within the skull.
Choice C Reason:
The client is unable to remember details of the motor-vehicle crash. Memory impairment or amnesia regarding the event can occur due to head trauma, but it might not directly correlate with an increase in intracranial pressure. It's more related to the effects of the injury on memory function.
Choice D Reason:
The client reports ringing in the ears. Tinnitus or ringing in the ears might occur in some cases of head trauma but is not a direct indicator of increased intracranial pressure. It might result from the impact of the injury or other associated factors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Experiences nocturia is incorrect. Nocturia (waking up at night to urinate) is a common symptom and, while it's important to address for the client's comfort and potential underlying causes, it doesn't pose an immediate risk to the client's roommate or necessitate urgent intervention in a shared room setting.
Choice B Reason:
History of generalized anxiety disorder is incorrect. A history of generalized anxiety disorder is relevant to the client's mental health and overall care. However, in the context of a shared room, it might not require immediate attention or interventions that directly impact the roommate's health or safety.
Choice C Reason:
Recent exposure to tuberculosis is correct. Tuberculosis (TB) is an infectious disease that spreads through the air when an infected person coughs or sneezes. In a shared room, a history of recent exposure to TB is a significant concern as it poses a potential risk to both the client and the roommate. Immediate measures to prevent transmission and ensure proper isolation protocols are necessary to protect the health of both individuals in the shared space.
Choice D Reason:
Reports periodic migraine headaches is correct.
Periodic migraine headaches are a health concern for the client experiencing them, but they typically do not pose an immediate risk or concern for the client's roommate. While addressing pain management is important, it might not require immediate action in the shared room environment.
Correct Answer is A
Explanation
A. Elevate the head of the client's bed for 1 hr after the feeding:Elevating the head of the bed helps prevent aspiration and promotes proper digestion by using gravity to keep the feeding solution in the stomach or jejunum.
B. Administer the feeding solution at a cold temperature: Feeding solutions should be administered at room temperature to prevent gastrointestinal discomfort or cramping.
C. Rotate the jejunostomy tube once per day:
Rotation of the jejunostomy tube is not a standard practice. Jejunostomy tubes are typically secured in place, and rotation is not necessary.
D. Flush the tube with 90mL of sterile water before and after the feeding:
Typically, the tube is flushed with about 30 mL of water before and after feedings to ensure patency and prevent clogging, not 90 mL.
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