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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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because a pneumothorax is a condition in which air enters the pleural space and causes the lung to collapse. It does not cause the chest wall to move inward and outward paradoxically.
Choice B Reason: This is incorrect because atelectasis is a condition in which alveoli collapse and cause reduced gas exchange. It does not cause the chest wall to move inward and outward paradoxically.
Choice C Reason: This is correct because flail chest is a condition in which multiple ribs are fractured and cause a segment of the chest wall to detach from the rest of the thoracic cage. It causes the chest wall to move inward and outward paradoxically, as well as dyspnea and pain.
Choice D Reason: This is incorrect because a hemothorax is a condition in which blood enters the pleural space and causes the lung to collapse. It does not cause the chest wall to move inward and outward paradoxically.
Correct Answer is A
Explanation
Choice A Reason: Dobutamine is a positive inotropic agent that increases the contractility of the heart and improves cardiac output. This leads to increased renal perfusion and urine output, which reduces the fluid overload and edema associated with heart failure. Therefore, this choice is correct.
Choice B Reason: Dobutamine does not have a direct effect on blood glucose level. It may cause hyperglycemia as a side effect, but this is not an indication of its effectiveness. Therefore, this choice is incorrect.
Choice C Reason: Dobutamine may cause a slight decrease in blood pressure due to vasodilation, but this is not its main therapeutic effect. A significant decrease in blood pressure may indicate hypovolemia, hypotension, or shock, which are adverse effects of dobutamine. Therefore, this choice is incorrect.
Choice D Reason: Dobutamine also has a positive chronotropic effect, which means it increases the heart rate. However, this is not a desired outcome for a client with heart failure, as it increases the oxygen demand of the heart and may worsen the condition. Therefore, this choice is incorrect.
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