A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

Administer pain medication as needed.

Maintain ventriculostomy at the correct position.

Maintain the neck in the midline position.

Elevate the head of the bed to 150.

Maintain enteral feedings.

Answer and Explanation

Correct Answer : A,B,C,D,E

A. Administer pain medication as needed. Rationale: Pain management is essential for clients with traumatic brain injury (TBI) to ensure their comfort and to prevent agitation or increased intracranial pressure (ICP) due to pain. Administering pain medication as needed helps alleviate discomfort and promotes rest, which supports the client's recovery.

B. Maintain ventriculostomy at the correct position. Rationale: Ventriculostomy, also known as an external ventricular drain (EVD), is a critical component of managing intracranial pressure (ICP) in clients with traumatic brain injury. Maintaining the ventriculostomy at the correct position ensures accurate monitoring and drainage of cerebrospinal fluid (CSF), which helps control ICP levels and prevents complications such as cerebral edema.

C. Maintain the neck in the midline position. Rationale: Keeping the neck in a midline position is essential for clients with traumatic brain injury to prevent further injury to the cervical spine. Proper alignment of the neck helps maintain spinal stability and reduces the risk of exacerbating any existing spinal cord injury, which may coexist with the traumatic brain injury.

D. Elevate the head of the bed to 30 degrees. Rationale: Elevating the head of the bed to 30 degrees is recommended for clients with traumatic brain injury to promote cerebral venous drainage and reduce intracranial pressure (ICP). This position helps optimize cerebral perfusion and minimizes the risk of cerebral edema, which can occur with increased ICP.

E. Maintain enteral feedings. Rationale: Nutritional support is crucial for clients with traumatic brain injury to support healing and recovery. Enteral feedings, such as tube feedings, may be necessary if the client is unable to consume adequate nutrition orally due to impaired swallowing or altered consciousness. Providing enteral feedings ensures the client receives essential nutrients to support tissue repair and prevent malnutrition-related complications during the recovery process.

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Correct Answer is B

Explanation

A. Septal myectomy: Septal myectomy is a surgical procedure primarily used to treat hypertrophic cardiomyopathy (HCM), not atrial fibrillation. It involves removing a portion of the thickened septal wall in the heart to improve blood flow.

B. Synchronized electrical cardioversion: Synchronized electrical cardioversion is a procedure used to convert abnormal heart rhythms, such as atrial fibrillation, back to normal sinus rhythm. It involves delivering a synchronized electrical shock to the heart at a specific point in the cardiac cycle to restore normal rhythm.

C. Pericardiocentesis: Pericardiocentesis is a procedure used to remove fluid from the pericardial sac surrounding the heart. It is typically performed to relieve cardiac tamponade or to investigate the cause of pericardial effusion.

D. Pericardial window: A pericardial window is a surgical procedure performed to create a permanent opening in the pericardium, the sac surrounding the heart. It is usually done to drain fluid or air from the pericardial space, often in cases of recurrent pericardial effusion or cardiac tamponade.

A. Open-angle glaucoma B. Macular degeneration C. Meniere’s disease D. Retinal detachment

Correct Answer is D

Explanation

A. Open-angle glaucoma: Open-angle glaucoma typically presents with increased intraocular pressure and gradual loss of peripheral vision, not with bright flashes of light and dark floating spots.

B. Macular degeneration: Macular degeneration is characterized by central vision loss, not by bright flashes of light and dark floating spots.

C. Meniere’s disease: Meniere’s disease is a disorder of the inner ear characterized by episodes of vertigo, hearing loss, and tinnitus. It does not typically cause bright flashes of light and dark floating spots in the visual field.

D. Retinal detachment: Trauma, such as being tackled while playing football, can lead to retinal detachment, which can manifest with symptoms such as bright flashes of light (photopsia) and dark floating spots (floaters) in the affected eye. This condition is considered a medical emergency and requires prompt evaluation and treatment to prevent permanent vision loss.

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A nurse is planning care for a client who has a traumatic brain injury (TBI). Which of the following nursing interventions should be added to the plan of care? (Select All that Apply.)

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