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 B
Explanation
The correct answer is: d. Brachial pulse in the right arm.
Choice A reason: Palpating the radial pulse in the right arm is not the most appropriate choice following a cardiac catheterization with a left antecubital insertion site. While it is contralateral to the insertion site, the brachial pulse is preferred over the radial pulse for assessing circulation in the arm, as it is more proximal and can provide a better indication of arterial flow from the catheterization site.
Choice B reason: The radial pulse in the left arm is the correct choice because it evaluates distal circulation in the affected limb. Since the catheterization was performed through the left antecubital fossa, it is crucial to monitor blood flow further down in the arm. Palpating the radial pulse helps detect early signs of compromised perfusion, such as diminished pulse strength. Evidence-based guidelines from clinical sources highlight the importance of distal pulse assessment post-catheterization.
Choice C reason: Palpating the brachial pulse in the left arm is also not recommended. Since the catheterization was performed on the left side, there is a risk of arterial occlusion or spasm, which could affect the accuracy of the pulse assessment in the left arm.
Choice D reason: The brachial pulse in the right arm does not provide relevant information about the left arm’s vascular status post-catheterization. Since the right arm was not affected by the procedure, its pulse does not indicate possible complications in the left arm. Clinical assessment should focus on detecting perfusion issues in the limb where the catheter was inserted. Best practices recommend prioritizing the evaluation of circulation in the affected extremity.
Correct Answer is D
Explanation
Choice A: Decreased specific gravity is not a finding of right-sided heart failure. Specific gravity is a measure of urine concentration, which can be affected by fluid intake, dehydration, kidney function, and diuretic use. Right-sided heart failure does not directly affect urine concentration, but it can cause fluid retention and edema in the body.
Choice B: Decreased brain natriuretic peptide (BNP) is not a finding of right-sided heart failure. BNP is a hormone that is released by the heart when it is stretched or overloaded. BNP helps to lower blood pressure and reduce fluid volume by increasing urine output and dilating blood vessels. BNP levels are elevated in both left-sided and right- sided heart failure, as the heart is under increased pressure and volume.
Choice C: Increased pulmonary artery wedge pressure (PAWP) is not a finding of right-sided heart failure. PAWP is a measure of the pressure in the left atrium, which reflects the pressure in the pulmonary capillaries. PAWP is elevated in left-sided heart failure, as the blood backs up in the lungs due to impaired left ventricular function. PAWP is normal or low in right-sided heart failure, as the blood backs up in the systemic circulation due to impaired right ventricular function.
Choice D: Elevated central venous pressure (CVP) is a finding of right-sided heart failure. CVP is a measure of the pressure in the right atrium, which reflects the pressure in the systemic venous system. CVP is elevated in right-sided heart failure, as the blood backs up in the body due to impaired right ventricular function. CVP can cause jugular venous distension, hepatomegaly, splenomegaly, ascites, and peripheral edema.
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