A nurse is reviewing discharge instructions with the family of a client who sustained a minor head injury earlier in the day. Which of the following instructions should the nurse include?
Apply heat to the area of swelling for the first 48 hr.
Repeatedly ask the client questions to check for orientation.
Do not let the client engage in strenuous activities for 1 week.
Encourage the client to sleep for the first 24 hr.
The Correct Answer is C
The nurse should instruct the family to not let the client engage in strenuous activities for 1 week following a minor head injury. This can help prevent further injury and allow the client to rest and recover.
Applying heat to the area of swelling for the first 48 hr, repeatedly asking the client questions to check for orientation, and encouraging the client to sleep for the first 24 hr are not appropriate instructions for the nurse to include in this situation. Applying heat can increase swelling and inflammation. Repeatedly asking the client questions can be disorienting and confusing. Encouraging the client to sleep for the first 24 hr is not necessary and could interfere with monitoring the client's condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
a. Auscultation of lungs revealing wheezing is not related to venous return in the affected arm. Wheezing is
a high-pitched whistling sound made while breathing and is usually a sign of a respiratory problem.
b.A bounding distal pulse indicates strong arterial blood flow, which is not a sign of impaired venous return. Impaired venous return would more likely result in a weak or absent pulse.
c. Fever could indicate infection but is not specific to impaired venous return. It's a systemic sign that may or may not be related to the cast or the fracture.
d. Pain that is unrelieved by opioid analgesics can be a sign of compartment syndrome, which is a serious complication that can result from impaired venous return and increased pressure within the muscle compartments. This requires immediate medical attention to prevent permanent damage.
Correct Answer is C
Explanation
When contributing to the plan of care for a client who is postoperative following a total hip arthroplasty, the nurse should include information on preventing hip flexion of the affected extremity. This can help prevent dislocation of the new hip joint and promote healing.
a. Positioning the lower extremities so that they are touching is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the lower extremities should be determined by the surgeon's instructions and the client's comfort.
b. Ensuring that the client's heels are touching the bed is not necessary for a client who is postoperative following a total hip arthroplasty. The position of the heels should be determined by the surgeon's instructions and the client's comfort.
d. Instructing the client to avoid movement of the affected leg is not necessary for a client who is postoperative following a total hip arthroplasty. The client will need to begin moving and exercising the affected leg as part of their rehabilitation and recovery.
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