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?

Choice A Reason:

"You will not become fatigued when you use assistive devices. “This statement might provide an unrealistic expectation. While assistive devices can help, they might still require physical effort and could potentially cause fatigue, especially during initial use or extended periods.

Choice B Reason:

"Plan to hire a home care aid to perform all of your ADLs." This statement is not appropriate.

While home care assistance can be beneficial, aiming to have someone perform all ADLs might limit the client's independence and ability to regain skills. The goal is often to support the client in performing ADLs independently whenever possible.

Choice C Reason:

"Install grab bars in your shower to assist with your balance." This statement is true. Installing grab bars in the shower can significantly enhance safety and stability during activities like showering, reducing the risk of falls for someone who might experience balance or mobility challenges following a CVA.

Choice D Reason:

"Place a towel in the shower to prevent slipping." This statement is inappropriate. While placing a towel might offer some traction, it might not provide sufficient stability or support, especially for someone with balance issues post-CVA. Grab bars offer more reliable support to prevent falls in the shower.

Choice A Reason

Using a hair dryer to blow hot air into the cast is not recommended. It can cause burns, soften the cast material, or create hot spots, potentially leading to skin damage or discomfort for the client.

Choice B Reason:

Perform neurovascular checks of the affected extremity every 2 hours is correct. Performing neurovascular checks regularly is crucial to assess the circulation, sensation, and movement of the affected extremity. This monitoring helps identify any signs of compromised blood flow or nerve function, which could indicate complications such as compartment syndrome.

Choice C Reason:

Positioning the fractured arm below the level of the client's heart is not advisable. Elevating the injured limb above heart level can help reduce swelling and promote blood flow, aiding in the healing process and preventing complications like swelling-related discomfort or decreased circulation.

Choice D Reason:

Immobilizing the client's fingers using a hand splint might not be necessary with a short arm cast. Typically, a short arm cast provides immobilization of the wrist and forearm while allowing some movement and function of the fingers unless specifically directed by the healthcare provider for individual circumstances.