A nurse is educating a group of nursing students about brain herniation.
Which of the following interventions should the nurse include as a potential treatment for brain herniation?

Hyperventilate the patient.

Decrease sedation.

Reduce the temperature in the room.

Lower blood pressure.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Hyperventilation is a potential treatment for brain herniation. Hyperventilation causes a decrease in carbon dioxide levels in the blood, leading to vasoconstriction of the cerebral blood vessels. This reduces cerebral blood flow and decreases intracranial pressure, which can help in the management of brain herniation.

Choice B rationale

Decreasing sedation is not typically a treatment for brain herniation. Sedation can be used in the management of increased intracranial pressure, but it is not a direct treatment for brain herniation.

Choice C rationale

Reducing the temperature in the room is not a direct treatment for brain herniation. While temperature control is important in the overall management of a patient with brain injury, it does not directly treat brain herniation.

Choice D rationale

Lowering blood pressure is not a direct treatment for brain herniation. While maintaining optimal blood pressure is important in the management of brain injury, aggressive lowering of blood pressure is not typically done as it could compromise cerebral perfusion.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Action	Essential	Nonessential	Contraindicated
Increasing IV fluid rate		The current rate is prescribed by the provider; increasing it without further assessment could lead to complications.
Encouraging the client to sit up without assistance		The client feels faint upon sitting up and is unsteady, so this could be dangerous.
Administering antiemetic medication	Helpful but not immediately critical.
Monitoring respiratory rate closely	Crucial due to client's rapid breathing and anxiety.
Providing reassurance and calming interventions	Important due to client's anxiety and discomfort.
Checking electrolyte levels regularly	Essential for ongoing monitoring given the client's symptoms.

Essential

Monitoring respiratory rate closely: The client is breathing rapidly and appears anxious, making close monitoring crucial to ensure timely intervention and management of respiratory issues.
Providing reassurance and calming interventions: The client is anxious and discomforted. Providing reassurance and calming interventions is important to address their immediate emotional and psychological needs.
Checking electrolyte levels regularly: Given the client's symptoms and the need for ongoing monitoring, checking electrolyte levels is essential for managing their condition effectively.

Nonessential

Administering antiemetic medication: While helpful for managing nausea, this action is not immediately critical compared to other interventions that address more urgent needs.

Contraindicated

Encouraging the client to sit up without assistance: The client feels faint and is unsteady when sitting up. Encouraging them to sit up without assistance could be dangerous and may increase the risk of falls or injuries.
Increasing IV fluid rate: The current IV fluid rate is prescribed by the provider. Increasing it without further assessment could lead to complications and should be avoided unless directed by a healthcare provider.

A. Stand directly in front of the patient when talking. B. Know the layout of the facility. C. Bring security with you for all patient interactions. D. Provide immediate verbal feedback for escalating behavior. E. Avoid wearing necklaces during patient care.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale

Standing directly in front of a patient who has a history of anger and aggression can be perceived as threatening and may escalate the situation.

Choice B rationale

Knowing the layout of the facility can help the nurse to plan for safe exits or to put barriers between themselves and the patient if needed.

Choice C rationale

Bringing security for all patient interactions can escalate the situation and should only be done if there is a clear threat to safety.

Choice D rationale

Providing immediate verbal feedback for escalating behavior can help to de-escalate the situation and reassure the patient.

Choice E rationale

Avoiding wearing necklaces during patient care can reduce the risk of injury to the nurse.

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A nurse is educating a group of nursing students about brain herniation.Which of the following interventions should the nurse include as a potential treatment for brain herniation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

Essential

Nonessential

Contraindicated

A nurse manager is providing staff education about working with patients who have a history of anger and aggression.Which of the following information should the nurse include in the teaching?

Correct Answer is ["B","D","E"]

Explanation

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A nurse is educating a group of nursing students about brain herniation.
Which of the following interventions should the nurse include as a potential treatment for brain herniation?