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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because dabigatran does not affect the electrical activity of the heart or the conduction system. It does not slow down the ventricular response to the atrial impulses.
Choice B Reason: This is incorrect because dabigatran does not dissolve existing clots in the bloodstream. It only prevents new clots from forming.
Choice C Reason: This is correct because dabigatran reduces the risk of stroke in clients who have atrial fibrillation by preventing clot formation and reducing blood viscosity. Dabigatran is an anticoagulant medication that prevents the formation of blood clots in the heart and blood vessels. Atrial fibrillation is a condition where the atria beat irregularly and rapidly, which can cause blood to pool and clot in the heart chambers. These clots can travel to the brain and cause a stroke. Dabigatran reduces the risk of stroke by preventing clot formation and reducing blood viscosity.
Choice D Reason: This is incorrect because dabigatran does not restore normal sinus rhythm in clients who have atrial fibrillation. It does not affect the heart rate or rhythm.
Correct Answer is C
Explanation
Choice A: Check the tubing connections for leaks is not an action that the nurse should take. Leaks in the tubing connections can cause continuous or intermitent bubbling in the water seal chamber, not in the suction control chamber. The water seal chamber is the part of the closed chest drainage system that prevents air from entering the pleural space and allows air to escape from the chest tube. The nurse should check the tubing connections for leaks if there is bubbling in the water seal chamber and tighten them if necessary.
Choice B: Check the suction control outlet on the wall is not an action that the nurse should take. The suction control outlet on the wall is the source of negative pressure that helps drain fluid and air from the pleural space and maintain a patent chest tube. The suction control chamber is the part of the closed chest drainage system that regulates the amount of negative pressure applied to the chest tube. The nurse should check the suction control outlet on the wall if there is no bubbling in the suction control chamber and adjust it as prescribed.
Choice C: Continue to monitor the client's respiratory status is an action that the nurse should take. Slow, steady bubbling in the suction control chamber is an expected finding that indicates that the suction is working properly and that there are no leaks in the system. The nurse should continue to monitor the client's respiratory status and assess for signs of respiratory distress, such as dyspnea, tachypnea, cyanosis, or decreased oxygen saturation.
Choice D: Clamping the chest tube is not an action that the nurse should take. Clamping the chest tube can cause a tension pneumothorax, which is a life-threatening condition characterized by a buildup of air in the pleural space that compresses the lung and shifts the mediastinum. The nurse should only clamp the chest tube temporarily and briefly for specific purposes, such as changing or troubleshooting the drainage system, or as prescribed by the provider.
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