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

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A Reason: This is the correct choice. Using the rule of nines, each arm accounts for 9 percent of TBSA, each leg accounts for 18 percent of TBSA, and front and back are equally divided. Therefore, burns on both sides of both arms and legs equal to (9 + 9) x 2 + (18 + 18) x 2 = 36 percent of TBSA.

Choice B Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 54 percent. To get 54 percent of TBSA, one would have to add burns on both sides of head and neck (9 percent), chest (9 percent), and abdomen (9 percent).

Choice C Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 27 percent. To get 27 percent of TBSA, one would have to subtract burns on both sides of one leg (18 percent).

Choice D Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 18 percent. To get 18 percent of TBSA, one would have to divide burns on both sides of both arms and legs by two.

Choice E Reason: This choice is incorrect. Using the rule of nines, burns on both sides of both arms and legs equal to 36 percent of TBSA, not 9 percent. To get 9 percent of TBSA, one would have to divide burns on both sides of both arms and legs by four.

A. Provide written materials and visual aids B. Use American Sign Language C. Shout at the client from 6 inches away D. Speak to the client in an everyday conversational tone

Correct Answer is D

Explanation

Choice A Reason: Providing written materials and visual aids is not necessary for a client who has hearing at 15 dB, which is considered normal hearing. Normal hearing ranges from 0 to 20 dB, meaning that the person can hear sounds that are as faint as 20 dB or less.

Choice B Reason: Using American Sign Language is not appropriate for a client who has hearing at 15 dB, which is considered normal hearing. American Sign Language is a form of communication that uses hand gestures, facial expressions, and body movements to convey meaning. It is mainly used by people who are deaf or hard of hearing.

Choice C Reason: Shouting at the client from 6 inches away is not advisable for a client who has hearing at 15 dB, which is considered normal hearing. Shouting can be perceived as rude or aggressive, and can damage the hearing of both the speaker and the listener.

Choice D Reason: Speaking to the client in an everyday conversational tone is the best action for a client who has hearing at 15 dB, which is considered normal hearing. Conversational speech ranges from 40 to 60 dB, meaning that the person can hear sounds that are as loud as 60 dB or less.

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A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is A

Explanation

The results of a client's audiogram indicate that the client has hearing at 15 decibels (dB). What action should the nurse take when communicating to the client?

Correct Answer is D

Explanation

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