Here is the edited text:
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

Administer a vasodilator medication.

Elevate the head of the bed to 30°.

Apply a cold compress to the forehead.

Decrease the oxygen ﬂow rate.

Answer and Explanation

The Correct Answer is B

Choice A Reason: This choice is incorrect because administering a vasodilator medication may lower the blood pressure and worsen the cerebral perfusion. A vasodilator medication is a drug that relaxes the blood vessels and reduces the resistance to blood ﬂow. It may be used for clients who have hypertension, angina, or heart failure, but it does not help to reduce the intracranial pressure (ICP).

Choice B Reason: This choice is correct because elevating the head of the bed to 30° may help to improve the venous drainage and decrease the ICP. ICP is the pressure exerted by the brain tissue, cerebrospinal ﬂuid (CSF), and blood within the cranial cavity. A normal ICP range is 5 to 15 mm Hg, and an elevated ICP (>20 mm Hg) can cause cerebral ischemia, herniation, or death. Therefore, positioning the client in a semi-Fowler's position (30° angle) or high- Fowler's position (60° to 90° angle) can facilitate breathing and prevent further complications.

Choice C Reason: This choice is incorrect because applying a cold compress to the forehead may cause vasoconstriction and increase the ICP. A cold compress is a device that applies cold temperature to a body part to reduce inﬂammation, pain, or swelling. It may be used for clients who have headaches, sprains, or bruises, but it does not help to reduce the ICP.

Choice D Reason: This choice is incorrect because decreasing the oxygen ﬂow rate may cause hypoxia and worsen the cerebral ischemia. Hypoxia is a condition in which the body or a part of it does not receive enough oxygen. It may cause symptoms such as confusion, agitation, or cyanosis. Therefore, providing adequate oxygenation and ventilation is essential to maintain the brain function and prevent further damage.

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Correct Answer is A

Explanation

Choice A Reason: Packed RBCs are indicated for clients who have hypovolemic shock due to blood loss, as they increase the oxygen-carrying capacity of the blood and restore the blood volume.

Choice B Reason: Cryoprecipitates are indicated for clients who have hemophilia or von Willebrand disease, as they contain clotting factors that help stop bleeding.

Choice C Reason: Albumin is indicated for clients who have hypovolemic shock due to ﬂuid loss, such as from burns or ascites, as it increases the plasma oncotic pressure and draws ﬂuid into the vascular space.

Choice D Reason: Platelets are indicated for clients who have thrombocytopenia or platelet dysfunction, as they help prevent or control bleeding.

A. Eliciting the gag reﬂex B. Testing visual acuity C. Observing for facial symmetry D. Checking the pupillary response to light

Correct Answer is D

Explanation

Choice A: Eliciting the gag reﬂex is a way to assess cranial nerve IX (glossopharyngeal) and X (vagus), which are responsible for the sensation and motor function of the pharynx and larynx.

Choice B: Testing visual acuity is a way to assess cranial nerve II (optic), which is responsible for the sense of vision.

Choice C: Observing for facial symmetry is a way to assess cranial nerve VII (facial), which is responsible for the motor function of the facial muscles and the sensation of taste.

Choice D: Checking the pupillary response to light is a way to assess cranial nerve III (oculomotor), which is responsible for the motor function of most of the eye muscles, including those that control pupil size and lens shape.

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Here is the edited text: A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?

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Here is the edited text:
A nurse is caring for a client who has a traumatic brain injury. The nurse notes that the client has a widening pulse pressure. Which of the following actions should the nurse take?