After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

Assess the client's serum sodium level.

Continue to monitor the client's urinary output.

Increase the rate of the IV infusion.

Administer desmopressin IV per protocol.

Answer and Explanation

The Correct Answer is A

Choice A reason:

Assessing the client's serum sodium level is the priority action. The symptoms of generalized edema, decreased urine output, acute confusion, and muscle weakness are suggestive of possible hyponatremia or other electrolyte imbalances, which can be critical in the postoperative period following a craniotomy. Checking the serum sodium level will provide essential information to guide further treatment.

Choice B reason:

While continuing to monitor the client's urinary output is important, it does not address the immediate need to diagnose and correct a potential electrolyte imbalance. The nurse needs to take action to determine the underlying cause of the patient's symptoms.

Choice C reason:

Increasing the rate of the IV infusion could potentially worsen the patient's condition, especially if the symptoms are related to fluid overload or electrolyte imbalance. This action should only be taken based on specific clinical indications and after appropriate assessments.

Choice D reason:

Administering desmopressin IV per protocol is not appropriate as the first action without confirming the underlying cause of the symptoms. Desmopressin is used for specific conditions such as diabetes insipidus, and its administration should be based on a confirmed diagnosis.

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Correct Answer is A

Explanation

Choice A reason:

Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.

Choice B reason:

While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.

Choice C reason:

Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.

Choice D reason:

Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.

A. Autonomic dysreflexia B. Ischemia C. Edema D. Axial loading E. Hemorrhage

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.

Choice B reason:

Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.

Choice C reason:

Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.

Choice D reason:

Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.

Choice E reason:

Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.

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After a craniotomy, the nurse assesses the patient and finds generalized edema, decreased urine output, acute confusion, and muscle weakness. The client has IV fluids running at 75 mL/hr. What action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Correct Answer is A

Explanation

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

Correct Answer is ["A","B","C","E"]

Explanation

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