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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Take this medication with orange juice is incorrect; alendronate should be taken with plain water to avoid food or drink interactions.

B. Take this medication with food is incorrect; alendronate should be taken on an empty stomach to enhance absorption.

C. Sit upright or stand for at least 30 minutes after taking this medication helps prevent esophageal irritation and ensure the medication reaches the stomach.

D. Chew or suck on the tablet is incorrect; the effervescent tablet should be dissolved in water as directed.

A. Hypotension B. Bone pain C. Bradypnea D. Slurred speech E. Pruritus

Correct Answer is ["B","D","E"]

Explanation

A. Hypotension is not typically associated with ESRD; hypertension is more common due to fluid retention and alterations in renin-angiotensin system.
B. Bone pain is common in ESRD due to disturbances in calcium and phosphate metabolism, leading to renal osteodystrophy.
C. Bradypnea is not an expected finding; however, patients may exhibit Kussmaul respirations if they have metabolic acidosis.
D. Slurred speech is a typical finding in ESRD.
E. Pruritus is a common symptom in ESRD due to the buildup of uremic toxins and alterations in calcium and phosphate metabolism.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 teaching a client who is starting to take alendronate effervescent tablets to treat osteoporosis. Which of the following information should the nurse include?

Correct Answer is C

Explanation

A nurse is caring for a client who has end-stage renal disease (ESRD). Which of the following are expected findings? (Select all that apply).

Correct Answer is ["B","D","E"]

Explanation

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to a client who has an implantable cardioverter/defibrillator (ICD). Which of the following information should the nurse include?

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A nurse is caring for a client who has undergone a transurethral prostatectomy. Following catheter removal, the nurse should inform the client that he should expect which of the following variations in the color of his urine?

A nurse is caring for a client who has a fractured tibia as a result of a fall. The client’s x-ray shows that the bone is splintered into several pieces around the shaft. The nurse should identify that the client has which of the following types of fractures?

A nurse is caring for a 75-year-old male client who is experiencing difficulty breathing and shortness of breath. Exhibits The nurse is caring for the client following a thoracentesis. (Select the 3 findings that require immediate follow-up.)

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?