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.

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Correct Answer is D

Explanation

Choice A Reason:

Taking medicine with orange juice is not recommended for clients with GERD. Citrus juices, including orange juice, are highly acidic and can exacerbate GERD symptoms by increasing stomach acidity and causing reflux.

Choice B Reason:

A bedtime snack is likely to worsen heartburn rather than prevent it. Eating close to bedtime can increase the likelihood of acid reflux during the night, as lying down soon after eating can cause stomach contents to flow back into the esophagus.

Choice C Reason:

Lying down after meals is not advisable for clients with GERD. It is recommended to remain upright for at least 2-3 hours after eating to help prevent acid reflux. Lying down can increase the risk of stomach acid flowing back into the esophagus.

Choice D Reason:

Limiting activities that require bending at the waist is a good practice for managing GERD. Bending over can increase abdominal pressure and promote acid reflux. Instead, clients should try to bend at the knees or avoid such activities when possible.

A. The client reports relief from pain when lying in the prone position. B. The client reports that their low-back pain radiates upward toward one scapula. C. The client reports tingling and a burning sensation in one foot. D. The client reports decreased pain when the affected leg is raised.

Correct Answer is C

Explanation

Choice A Reason

The client reports relief from pain when lying in the prone position. This statement is incorrect. Clients with a herniated lumbar disc typically find relief from pain when lying on their back with their knees bent or in a fetal position. Lying prone can sometimes exacerbate the pain.

Choice B Reason

The client reports that their low-back pain radiates upward toward one scapula. This statement is incorrect. Pain from a herniated lumbar disc usually radiates downward into the buttocks, legs, and sometimes the feet, not upward toward the scapula.

Choice C Reason

The client reports tingling and a burning sensation in one foot. This is the correct finding. A herniated lumbar disc can compress spinal nerves, leading to symptoms such as tingling, numbness, and a burning sensation in the legs and feet.

Choice D Reason

The client reports decreased pain when the affected leg is raised. This statement is incorrect. Raising the affected leg often increases pain due to the stretching of the sciatic nerve, which can be compressed by the herniated disc.

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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 providing discharge instructions to a client who has GERD. Which of the following statements by the client demonstrates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is assessing a client who has a herniated lumbar disc. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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