A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

Administer opioids.

Darken the room.

Apply restraints.

Reduce stimuli.

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect. Opioids are not indicated for a client who is emerging from a coma, as they can cause respiratory depression, sedation, and confusion. They may also mask the signs of increased intracranial pressure or neurological deterioration.

Choice B Reason: This is incorrect. Darkening the room may not be helpful for a client who is emerging from a coma, as it may increase their disorientation and agitation. The nurse should provide adequate lighting and orient the client to time, place, and person frequently.

Choice C Reason: This is incorrect. Applying restraints may worsen the restlessness and agitation of a client who is emerging from a coma, as they may perceive them as a threat or a restriction. Restraints may also increase the risk of injury, infection, or skin breakdown. The nurse should use restraints only as a last resort and with a physician's order.

Choice D Reason: This is correct. Reducing stimuli is an appropriate intervention for a client who is emerging from a coma, as it can help calm them and prevent sensory overload. The nurse should limit noise, visitors, and unnecessary procedures, and provide a quiet and comfortable environment.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because droplet precautions are not sufficient to prevent the transmission of pneumonic plague. Droplet precautions are used to prevent the spread of infectious agents that are expelled through coughing, sneezing, or talking and travel only a short distance in the air. Droplet precautions include wearing a surgical mask, gown, and gloves, and placing the client in a private room or with a roommate who has the same infection.

Choice B Reason: This is incorrect because administering an antitoxin is not an intervention for pneumonic plague. An antitoxin is a substance that neutralizes the eﬀects of a toxin produced by a microorganism. Pneumonic plague is not caused by a toxin, but by a bacterial infection.

Choice C Reason: This is correct because initiating airborne precautions is an intervention for pneumonic plague. Airborne precautions are used to prevent the spread of infectious agents that can remain suspended in the air and travel over long distances. Pneumonic plague is a severe and potentially fatal infection caused by the bacterium Yersinia pestis, which can be transmited through respiratory droplets or aerosols. Airborne precautions are used to prevent the spread of infectious agents that can remain suspended in the air and travel over long distances. Airborne precautions include wearing a respirator or N95 mask, placing the client in a negative-pressure room with an air filtration system, and limiting visitors and staﬀ contact.

Choice D Reason: This is incorrect because destroying the linens after use is not an intervention for pneumonic plague. Linens that are contaminated with body ﬂuids or secretions should be handled with gloves and placed in leak-proof bags for laundering or disposal, but they do not need to be destroyed.

A. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg B. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg C. pH 7.50, HCO3- 26 mEq/L, PaCO2 50 mm Hg D. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because these values indicate respiratory alkalosis, which is caused by hyperventilation or excess loss of carbon dioxide (PaCO2). Respiratory alkalosis increases the blood pH and decreases the HCO3- level.

Choice B Reason: This is incorrect because these values indicate metabolic alkalosis, which is caused by excess intake or retention of bases or loss of acids. Metabolic alkalosis increases the blood pH and the HCO3- level.

Choice C Reason: This is incorrect because these values indicate respiratory acidosis, which is caused by hypoventilation or excess retention of carbon dioxide (PaCO2). Respiratory acidosis decreases the blood pH and increases the HCO3- level.

Choice D Reason: This is correct because these values indicate metabolic acidosis, which is a common complication of chronic kidney disease. These values indicate metabolic acidosis, which is a common complication of chronic kidney disease. Metabolic acidosis occurs when the kidneys are unable to excrete excess acids or retain enough bicarbonate (HCO3-), which is a base that buﬀers the blood pH. As a result, the blood pH decreases and becomes more acidic. The normal range for blood pH is 7.35 to 7.45, for HCO3- is 22 to 26 mEq/L, and for PaCO2 is 35 to 45 mm Hg.

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