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 A

Explanation

A. Comminuted is correct. A comminuted fracture occurs when the bone breaks into several pieces, which matches the description of the tibia being splintered into multiple fragments.

B. Impacted is incorrect. An impacted fracture occurs when the ends of the bone are driven into each other.

C. Transverse is incorrect. A transverse fracture occurs in a straight line across the bone shaft.

D. Oblique is incorrect. An oblique fracture occurs at an angle across the bone shaft.

A. APTT 64 seconds B. Fibrinogen 85 mg/dL C. Platelets 156,000/mm³ D. PT 12 seconds

Correct Answer is B

Explanation

A. APTT of 64 seconds is prolonged but not specific to DIC alone; the normal range is generally around 30-40 seconds, and prolonged APTT can be seen in various conditions.
B. A fibrinogen level of 85 mg/dL is low. In DIC, fibrinogen levels decrease due to increased clotting and subsequent consumption of clotting factors.
C. A platelet count of 156,000/mm³ is within the normal range for most clients (150,000-450,000/mm³), though it might be lower in acute DIC.
D. A PT of 12 seconds is within the normal range for most clients (11-13.5 seconds), so it does not require reporting for DIC.

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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

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