A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care?
Encourage coughing and deep breathing
Position the patient with knees and hips flexed
Perform nursing interventions once an hour to provide rest periods
Keep the head of the bed elevated to 30 degrees
The Correct Answer is D
Choice A Reason: This is incorrect because encouraging coughing and deep breathing can increase intracranial pressure (ICP), which is the pressure inside the skull that can affect brain function. Coughing and deep breathing can increase blood flow and oxygen demand to the brain, which can worsen cerebral edema. The nurse should suction the patient as needed and maintain a patent airway.
Choice B Reason: This is incorrect because positioning the patient with knees and hips flexed can increase ICP by reducing venous drainage from the head. The nurse should position the patient with neck and body in alignment and avoid extreme flexion or extension of any joints.
Choice C Reason: This is incorrect because performing nursing interventions once an hour can disturb the patient's sleep and increase ICP by stimulating brain activity. The nurse should cluster nursing interventions and provide quiet and dark environment to promote rest and reduce stress.
Choice D Reason: This is correct because keeping the head of the bed elevated to 30 degrees can decrease ICP by facilitating venous drainage from the head and reducing cerebral blood volume. The nurse should monitor the patient's blood pressure and pulse to ensure adequate cerebral perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: A virus is not detected by the KOH test, which is used to diagnose fungal infections of the skin, hair, or nails. A virus can be detected by other tests, such as polymerase chain reaction (PCR) or viral culture.
Choice B Reason: A fungal infection is detected by the KOH test, which dissolves the skin cells and leaves behind the fungal elements that can be seen under a microscope. A fungal infection can cause symptoms such as itching, scaling, redness, or blisters.
Choice C Reason: A bacterial infection is not detected by the KOH test, which is specific for fungi. A bacterial infection can be detected by other tests, such as gram stain or culture.
Choice D Reason: Cancer is not detected by the KOH test, which is not a screening tool for malignancy. Cancer can be detected by other tests, such as biopsy or imaging.
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because administering medications and electrolytes is not the primary purpose of inserting a nasogastric tube for a client with acute peritonitis. Medications and electrolytes can be given through other routes, such as IV or oral.
Choice B Reason: This is incorrect because dilating the stomach as a presurgical preparation is not a relevant Reason for inserting a nasogastric tube for a client with acute peritonitis. Dilating the stomach may be done before some types of gastric surgery, but it does not apply to peritonitis.
Choice C Reason: This is incorrect because stating that you will not be able to eat for several days is not an adequate explanation for inserting a nasogastric tube for a client with acute peritonitis. This statement does not address the rationale or the benefits of the procedure. It may also cause anxiety and resentment in the client.
Choice D Reason: This is the correct choice because removing secretions and decompressing the stomach is the main Reason for inserting a nasogastric tube for a client with acute peritonitis. Peritonitis is an inflammation of the peritoneum, the membrane that lines the abdominal cavity. It can cause abdominal distension, pain, nausea, and vomiting. A nasogastric tube can suction out the gastric contents and reduce the pressure and irritation in the abdomen.
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