The charge nurse observes a new graduate nurse who is caring for a client who has a severe head injury. Which action by the new graduate nurse requires the charge nurse to intervene?
The new graduate nurse elevates the client's head of the bed to 30 degrees.
The new graduate nurse administers an analgesic before turning the client.
The new graduate nurse is frequently suctioning the client without breaks.
The new graduate nurse assesses the client's neurologic status every hour.
The Correct Answer is C
A. The new graduate nurse elevates the client's head of the bed to 30 degrees. Elevating the head of the bed to 30 degrees helps reduce ICP by promoting venous drainage from the brain.
B. The new graduate nurse administers an analgesic before turning the client. Analgesics are often necessary before turning a client with a head injury to minimize discomfort and prevent additional stress.
C. The new graduate nurse is frequently suctioning the client without breaks: Frequent suctioning without breaks can increase intracranial pressure (ICP) and compromise the patient's condition. Suctioning should be done with caution and only as needed, allowing for breaks in between to prevent ICP elevation.
D. The new graduate nurse assesses the client's neurologic status every hour. Regular neuro assessments are necessary for patients with head injuries to monitor changes in condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Decerebrate posturing: This involves extension and outward rotation of the arms, which is not observed here.
B. Decorticate posturing: Internal rotation, adduction, and flexion of the arms are characteristic of decorticate posturing, indicating damage to the corticospinal tract.
C. Flexion withdrawal: This refers to pulling away from a painful stimulus and does not involve the described pattern of movement.
D. Localization of pain: This is an intentional movement toward the source of pain, which is not demonstrated in this scenario.
Correct Answer is C
Explanation
A. Call the physician: While notifying the physician is important, it is not the immediate priority in a life-threatening situation like ventricular fibrillation.
B. Administer oxygen: Administering oxygen is helpful, but the immediate priority in ventricular fibrillation is to initiate life-saving measures.
C. Initiate cardiopulmonary resuscitation (CPR): Ventricular fibrillation is a life-threatening emergency, and initiating CPR immediately is crucial to restore circulation and improve chances of survival.
D. Give a dose of epinephrine: Epinephrine is part of the advanced cardiac life support (ACLS) protocol, but it should be administered after initiating CPR and defibrillation.
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