A nurse is collecting data from a client who has a traumatic head injury. Which of the following findings should the nurse report to the provider immediately?
Sudden sleepiness
Headache
Diplopia
Slight ataxia
The Correct Answer is A
The nurse should report sudden sleepiness to the provider immediately if the client has a traumatic head injury. Sudden sleepiness can indicate an increase in intracranial pressure, which can be a life-threatening complication of a head injury.
Headache, diplopia, and slight ataxia are also important findings that the nurse should report to the provider. However, these findings are not as urgent as sudden sleepiness. Headache can be a common symptom following a head injury. Diplopia is double vision and can indicate cranial nerve damage. Slight ataxia is unsteadiness or lack of coordination and can indicate neurological damage.
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Correct Answer is C
Explanation
To prevent autonomic dysreflexia, the nurse should take the intervention of preventing bladder distention. Autonomic dysreflexia is a serious medical problem that can happen if a person has injured the spinal cord in their upper back¹. It makes their blood pressure dangerously high and can lead to a stroke, seizure, or cardiac arrest¹. One way to lower the chance of complications is to use the bathroom on a regular schedule and keep the bladder and bowels from becoming too full.
a. Monitoring for elevated blood pressure is important but not an intervention to prevent autonomic dysreflexia.
b. Providing analgesia for headaches is important but not an intervention to prevent autonomic dysreflexia.
d. Elevating the client's head is important but not an intervention to prevent autonomic dysreflexia.
Correct Answer is B
Explanation
Halo-vest traction immobilizes a patient’s head and neck after traumatic injury to the cervical vertebrae as well as helping to prevent further injury to the spinal cord². Elevating the head of the bed can help improve the patient's comfort and reduce the risk of complications such as aspiration.
a. Placing the client in a supine position is not necessarily required for a patient in halo traction. The position of the patient should be determined by their individual needs and comfort.
c. Applying a pelvic girdle is not necessary for a patient in halo traction. Halo-vest traction consists of a metal ring that fits over the patient’s head and metal bars that connect the ring to a plastic vest that distributes the weight of the entire apparatus around the chest².
d. Elevating the foot of the bed is not necessary for a patient in halo traction. The position of the bed
should be determined by the patient's individual needs and comfort.
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