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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is incorrect because preparing the client for an X-ray is not the first action that the nurse should take. An X-ray can help diagnose possible injuries or fractures, but it is not an urgent test. The nurse should first assess the client's level of consciousness and neurological status using a standardized tool such as the Glasgow Coma Scale.
Choice B reason: This is the correct answer because calculating a Glasgow Coma Score is the first action that the nurse should take. The Glasgow Coma Scale is a tool that measures the level of consciousness based on the eye-opening, verbal response, and motor responses. It can help determine the severity of brain injury and guide further interventions.
Choice C reason: This is incorrect because dimming the lights and turning off the TV are not the first actions that the nurse should take. These are environmental modifications that can help reduce sensory stimulation and prevent agitation or seizures, but they are not as important as assessing the level of consciousness and neurological status.
Choice D reason: This is incorrect because providing analgesics is not the first action that the nurse should take. Analgesics can help relieve pain and discomfort, but they can also alter the level of consciousness and mask neurological signs. The nurse should first assess the level of consciousness and neurological status, and then administer analgesics as prescribed.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because right-sided homonymous hemianopsia means that the client has lost vision in the right half of both eyes, so placing food trays on the left side of the client will help them see and access their food better.
Choice B reason: This is incorrect because placing food trays on the right side of the client will make it harder for them to see and reach their food, as they have no vision on that side.
Choice C reason: This is incorrect because performing a focused visual exam is not an appropriate action for the nurse to take during meal time. The nurse should assess the client's vision before or after meals, but not interfere with their eating.
Choice D reason: This is incorrect because having the assistive personnel feed all meals to the client will decrease their independence and dignity, as well as their ability to practice using their unaffected side. The nurse should encourage and assist the client to feed themselves as much as possible, and only provide assistance when needed.
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