A nurse is contributing to the plan of care for a client who had a craniotomy. Which of the following interventions should the nurse include in the plan?
Apply a warm cloth over the client's eyes.
Place the client in a supine position.
Maintain seizure precautions.
Obtain a prescription for an opioid medication for pain.
The Correct Answer is C
a. Apply a warm cloth over the client's eyes: This intervention is not typically indicated for a client who had a craniotomy. It is important to monitor for signs of increased intracranial pressure, but a warm cloth over the eyes is not a standard intervention.
b. Place the client in a supine position: The position of the client after a craniotomy will depend on the surgeon's preference. It is important to follow specific postoperative positioning
instructions, which may or may not include supine positioning.
c. Maintain seizure precautions: Seizure precautions are crucial for clients who have had a craniotomy, as they are at an increased risk of seizures postoperatively.
d. Obtain a prescription for an opioid medication for pain: Pain management is important, but opioid medications may be carefully titrated due to the potential for respiratory depression and other side effects. It is not the primary intervention in the immediate postoperative period.
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Related Questions
Correct Answer is C
Explanation
a. Allow the client to take her morning vitamins: This is generally acceptable unless there are specific preoperative instructions regarding medication.
b. Allow the client to keep her tongue stud in: Metallic objects, including tongue studs, are
usually removed before surgery to prevent interference with equipment and to ensure patient safety.
c. Allow the client to keep her hearing aids in: It is important for the client with a hearing
impairment to keep hearing aids in place to facilitate communication and maintain awareness of the environment.
d. Allow the client to consume clear liquids up to the time of surgery: Clear liquids are typically restricted before surgery to prevent aspiration. This action may not align with standard
preoperative fasting guidelines.
Correct Answer is ["A","C","E"]
Explanation
a. Nausea: Nausea is a common symptom of myocardial infarction and can be associated with autonomic nervous system activation.
b. Orthopnea: Orthopnea, difficulty breathing while lying down, is more commonly associated with heart failure, not necessarily myocardial infarction.
c. Diaphoresis: Profuse sweating or diaphoresis is a common manifestation of myocardial infarction due to sympathetic nervous system activation.
d. Headache: Headache is not a typical symptom of myocardial infarction. However, some individuals may experience atypical symptoms.
e. Tachycardia: Tachycardia (rapid heart rate) is a common response to myocardial infarction and can be associated with sympathetic nervous system stimulation in response to decreased cardiac output.
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