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.

Answer and Explanation

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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Correct Answer is D

Explanation

An appropriate conclusion based on this data is that the client opens his eyes when spoken to. A GCS score of 3 for eye opening indicates that the client opens his eyes in response to voice.

The client is not unconscious, as a GCS score of 3 for eye opening indicates that the client is able to open his eyes in response to voice. The client is not unable to make vocal sound, as a GCS score of 5 for best verbal response indicates that the client is able to make vocal sounds. The client may or may not be able to follow simple motor commands, as a GCS score of 5 for best motor response indicates that the client is able to localize pain.

A. A client who has an arteriovenous malformation B. A client who has thrombocytopenia C. A client who has chronic atrial fibrillation D. A client who has uncontrolled hypertension

Correct Answer is C

Explanation

A client who has chronic atrial fibrillation is at risk for an ischemic embolic stroke. An ischemic embolic stroke occurs when a blood clot that forms in one part of the body travels to the brain and blocks blood ﬂow. Atrial fibrillation is a type of irregular heart rhythm that can cause blood to pool, thicken, and clot in the heart or arteries near it. Pieces of these clots can travel to the brain and cause an ischemic embolic stroke.

a. A client who has an arteriovenous malformation is not at risk for an ischemic embolic stroke.
b. A client who has thrombocytopenia is not at risk for an ischemic embolic stroke.
d. A client who has uncontrolled hypertension is at risk for a stroke but not specifically an ischemic embolic
stroke.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is D

Explanation

A nurse is planning care for several clients and is considering the clients' risk for stroke. Which of the following conditions places the client at risk for an ischemic embolic stroke?

Correct Answer is C

Explanation

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