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 A

Explanation

The nurse should call emergency medical services if they find a woman who has collapsed with right-sided weakness and slurred speech. These symptoms could indicate a stroke or other serious medical condition that requires immediate medical attention.

Finding a location for the client to sit, driving the client to the nearest emergency room, and obtaining the number of the client's provider are not appropriate initial actions for the nurse to take in this situation. The priority is to get the client immediate medical attention by calling emergency medical services.

A. Uneven cast drying B. Infection C. Pressure from the cast D. Poor circulation

Correct Answer is B

Explanation

The nurse should identify infection as a complication to the client's condition. A warm area on the cast could indicate the presence of an underlying infection. The warmth could be due to an increase in blood ﬂow to the area as the body tries to fight oﬀ the infection.

Uneven cast drying, pressure from the cast, and poor circulation are not complications that would cause a warm area on the cast. Uneven cast drying could cause discomfort but would not result in warmth. Pressure from the cast could cause skin breakdown but would not result in warmth. Poor circulation could cause coolness or pallor but would not result in warmth.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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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?