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 B

Explanation

A. Bright red urine would indicate active bleeding and is not an expected finding after catheter removal.
B. Pale pink urine is expected as some bleeding is normal following a transurethral prostatectomy.
C. Bright yellow urine is typical of normal, well-hydrated urine and is not expected immediately postoperatively.
D. Dark amber urine could indicate dehydration and is not typical following this procedure.

A. The client states having nasal congestion. B. The client states having a severe headache. C. The client's blood pressure becomes elevated. D. The client's bladder becomes distended.

Correct Answer is D

Explanation

A. Nasal congestion is not a primary sign of autonomic dysreflexia, though it can be a symptom of other conditions.

B. A severe headache can be a symptom of autonomic dysreflexia but is not the sole indicator of the condition.

C. Elevated blood pressure can be a result of autonomic dysreflexia but is not necessarily an indication of risk without other symptoms.

D. A distended bladder is a common trigger for autonomic dysreflexia in clients with a spinal cord injury at or above T-6, making it a key indicator for monitoring.

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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 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?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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