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 A
Explanation
The correct answer is: a. Place a black tag on the client’s upper body and attempt to help the next client in need.
Choice A: Place a black tag on the client’s upper body and attempt to help the next client in need.
In mass casualty incidents, the START (Simple Triage and Rapid Treatment) triage system is often used. According to this system, if a patient is apneic (not breathing) and does not resume breathing after repositioning the airway, they are considered deceased or non-salvageable and should be tagged with a black tag. This allows the nurse to focus on other victims who have a higher chance of survival.
Choice B: Start CPR
While starting CPR might seem appropriate in a normal setting, during a mass casualty incident, resources and time are limited. The priority is to save as many lives as possible. Performing CPR on an apneic patient with a weak pulse would take significant time and resources that could be used to help other victims with a higher chance of survival.
Choice C: Place a red tag on the client’s upper body and obtain immediate help from other personnel.
A red tag is used for patients who need immediate care and have a high chance of survival if treated promptly. Since the client remains apneic even after repositioning the airway, they do not meet the criteria for a red tag.
Choice D: Reposition the client’s upper airway a second time before assessing his respirations.
Repositioning the airway a second time is not recommended in the START triage system. If the patient does not resume breathing after the initial repositioning, they are considered non-salvageable.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect. Anginal pain usually lasts less than 20 min and subsides with rest or medication. Pain that lasts longer than 20 min may indicate a myocardial infarction.
Choice B Reason: This is incorrect. Anginal pain usually responds to rest and organic nitrates, such as nitroglycerin. Pain that does not improve with these measures may indicate unstable angina or a myocardial infarction.
Choice C Reason: This is incorrect. Anginal pain is not affected by the position of the client. Pain that is relieved by sitting up may indicate pericarditis or pleurisy.
Choice D Reason: This is correct. Anginal pain is caused by a temporary imbalance between the oxygen demand and supply of the myocardium. Factors that increase the oxygen demand, such as exertion, anxiety, cold, or heavy meals, can trigger anginal pain.
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