A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

Flex the client's hip.

Hyperextend the client's neck.

Provide warming measures for the client.

Adjust the client's head of bed.

Answer and Explanation

The Correct Answer is D

A. Flex the client’s hip is incorrect. Flexing the hip can increase intra-abdominal pressure and potentially increase intracranial pressure.

B. Hyperextend the client’s neck is incorrect. Hyperextension of the neck can interfere with venous return from the brain and increase ICP.

C. Provide warming measures for the client is incorrect. Warming measures are not indicated for a low CPP; maintaining normothermia is important, but warming is not the priority action.

D. Adjust the client’s head of bed is correct. Elevating the head of the bed helps reduce ICP and improves cerebral perfusion by promoting venous outflow.

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Correct Answer is C

Explanation

A. Measuring the circumference of the thigh can help assess for swelling but is not specific for neurovascular assessment.
B. Palpating the femoral pulse is not as relevant for assessing neurovascular status at the site of a femur fracture; instead, the focus is on more distal pulses and sensations.
C. Instructing the client to wiggle his toes assesses motor function and circulation to the distal extremities, which are crucial for neurovascular status.
D. Monitoring the calf for edema is not the primary method for assessing neurovascular status at the site of a femur fracture; it’s more relevant for assessing for deep vein thrombosis.

A. Irregular pulsations B. Bounding pulsations C. Tachycardia D. Bradycardia

Correct Answer is A

Explanation

A. Irregular pulsations are expected with PVCs because they cause occasional early beats that disrupt the regular rhythm of the pulse.

B. Bounding pulsations are not specific to PVCs and are more indicative of conditions like high cardiac output states.

C. Tachycardia is not a direct finding associated with PVCs; PVCs are more about irregular beats rather than a consistently high heart rate.

D. Bradycardia is not typically associated with PVCs; PVCs are characterized by irregular beats but not necessarily a slow heart rate.

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A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status?

Correct Answer is C

Explanation

A nurse on a telemetry unit is caring for a client who has premature ventricular contractions (PVCs). While sitting in a chair, the client reports feeling lightheaded. If the client is having PVCs, which of the following findings should the nurse expect when auscultating the client's apical pulse?

Correct Answer is A

Explanation

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