A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)

Infection

Vomiting

Widening pulse pressure

Equal and reactive pupils

Intracranial pressure reading of 10 mm Hg

Answer and Explanation

Correct Answer : A,B,C

Choice A Reason:

Infection is a significant complication of a ventriculostomy drain. The presence of a foreign object in the brain increases the risk of infections such as meningitis or ventriculitis. Signs of infection can include fever, redness, swelling at the insertion site, and changes in mental status.

Choice B Reason:

Vomiting can be a sign of increased intracranial pressure (ICP), which is a serious complication in clients with a traumatic brain injury and a ventriculostomy drain. Increased ICP can lead to further brain injury and requires immediate medical attention.

Choice C Reason:

Widening pulse pressure (the difference between systolic and diastolic blood pressure) can indicate increased intracranial pressure. This is a critical finding that should be reported immediately as it can signify worsening brain injury or other complications.

Choice D Reason:

Equal and reactive pupils are generally a normal finding and do not indicate a complication. This suggests that the brainstem is functioning properly and there is no significant increase in intracranial pressure affecting the cranial nerves.

Choice E Reason:

An intracranial pressure reading of 10 mm Hg is within the normal range (typically 7-15 mm Hg for adults). Therefore, this finding does not indicate a complication and does not require immediate reporting.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason:

The dressing for a PICC line should be changed every 7 days or sooner if it becomes wet, soiled, or loose. Therefore, a dressing change 7 days ago is within the recommended guidelines and does not necessarily require immediate notification of the provider.

Choice B Reason:

An increase in the circumference of the client’s upper arm by 10% can indicate swelling, which may be a sign of complications such as infection, thrombosis, or infiltration. This finding should be promptly reported to the provider for further evaluation and intervention.

Choice C Reason:

The catheter not being used for 8 hours is not typically a cause for concern as long as it is properly flushed and maintained. PICC lines can remain in place for extended periods without use, provided they are flushed regularly to prevent occlusion.

Choice D Reason:

Flushing the catheter with 10 mL of sterile saline after medication use is a standard practice to maintain patency and prevent blockage This action does not require notification of the provider unless there are other associated complications.

A. “It is okay to not want to touch the burned areas of your body.” B. “Cosmetic surgery should be performed within the next year to be effective.” C. “Reconstructive surgery can completely restore your previous appearance.” D. “It could be helpful for you to attend a support group for people who have burn injuries.”

Correct Answer is D

Explanation

Choice A Reason

“It is okay to not want to touch the burned areas of your body.” This statement is empathetic and acknowledges the client’s feelings, but it does not provide a constructive way to address their concerns about altered appearance. While it is important to validate the client’s feelings, offering a solution or support mechanism is more beneficial.

Choice B Reason

“Cosmetic surgery should be performed within the next year to be effective.” This statement is misleading. While timely intervention can be important, the timing of reconstructive or cosmetic surgery depends on various factors, including the extent of the burns, the healing process, and the patient’s overall health. It is not accurate to generalize that surgery must be performed within a year.

Choice C Reason

“Reconstructive surgery can completely restore your previous appearance.” This statement is incorrect and can give false hope. Reconstructive surgery aims to improve function and appearance, but it cannot completely restore the previous appearance. Managing expectations is crucial in the recovery process.

Choice D Reason

“It could be helpful for you to attend a support group for people who have burn injuries.” This statement is correct. Support groups provide emotional and psychological support, helping burn survivors cope with changes in appearance and other challenges. They offer a sense of community and shared experiences, which can be very beneficial for recovery.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is monitoring a client who has a traumatic brain injury and a ventriculostomy drain. The nurse should report which of the following findings as a complication of this therapeutic procedure? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following findings should the nurse notify the provider?

Correct Answer is B

Explanation

A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is postoperative and reports frequent leakage of small amounts of urine. The nurse notes that the client’s bladder is palpable upon examination. The nurse should identify these findings as which of the following forms of incontinence?

A nurse is planning care for a client who has Ménière’s disease and is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?

A nurse in a rural community is providing education to a group of clients about first aid interventions for snake bites to prevent further injury. Which of the following instructions should the nurse include in the teaching?

A nurse is providing teaching to a client who has a new onset of genital herpes. Which of the following statements should the nurse include in the teaching?

A nurse is reviewing laboratory reports for a client who is taking NSAIDs for rheumatoid arthritis. Which of the following results should the nurse recognize as a possible adverse effect of NSAID therapy?

A nurse is planning care for a client who has acute pancreatitis. Which of the following interventions should the nurse include in the client’s plan? (Select all that apply.)

A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?

A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hours ago. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)