Try Naxlex NCLEX-RN (Free-Trial)

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg.

The client has periorbital edema and ecchymosis.

The client prefers to rest in the semi-Fowler's position.

The client's level of consciousness has improved.

Answer and Explanation

The Correct Answer is A

The client's vital signs are temperature, 101.9 F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute, and blood pressure, 138/80 mm Hg. An elevated temperature is a significant finding that may indicate the presence of an infection, which can cause further neurological damage in a client with an intracranial injury. The physician should be notified promptly, as the client may require antibiotic therapy to prevent the spread of infection.

B. Periorbital edema and ecchymosis are normal findings following head injury and should be monitored but do not require immediate intervention.

C. Resting in semi-Fowler's position is an appropriate position to maintain after intracranial pressure-reducing surgery.

D. Improved level of consciousness is a positive finding and indicates that the client is responding well to treatment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Hyperkalemia. Confusion, abdominal cramping, racing heart rate, and numbness of the extremities are symptoms associated with hyperkalemia, a condition where the potassium level in the blood is too high.

Hypocalcemia, choice B, is characterized by muscle spasms, numbness, and tingling around the mouth and fingertips.

Elevated urea levels, choice C, may be associated with decreased urine output, fatigue, and shortness of breath.

Elevated white blood cells, choice D, may indicate an infection.

A. There will be blood and mucus initially exiting the stoma. B. The stoma will shrink a bit over a period of weeks. C. The stool will be of normal consistency and color. D. The stoma should be beefy red. E. Drainage will begin approximately 24-48 hours following surgery.

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

Explanation

Pre-operative education is successful when the client states that there will be blood and mucus initially exiting the stoma, the stoma will shrink a bit over a period of weeks, the stoma should be beefy red, and drainage will begin approximately 24-48 hours following surgery. These statements indicate that the client has a good understanding of what to expect after surgery.

Option C, The stool will be of normal consistency and color, is not a correct answer as the stool from an ostomy is different from normal stool consistency and color.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client in chronic renal failure becomes confused and complains of abdominal cramping, racing heart rate, and numbness of the extremities. The nurse relates these symptoms to which of the following lab values?

Correct Answer is A

Explanation

The nurse is providing patient education for a client who is going to have an ostomy created due to chronic Crohn's disease. The nurse has decided that pre- operative education is successful when the client states:. (select all that apply).

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

Explanation

A client experiences a musculoskeletal injury that involves the structure that connects a muscle to the bone. The nurse understands that this injury involves which of the following?

An older adult female has a bone density test that reveals severe osteoporosis. What does the nurse understand can be a problem for this client due to the decrease in bone mass and density?

Which assessment finding is most important in determining which client has a higher risk for testicular cancer?

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

A client is taking large amounts of salicylates for the treatment of bursitis of the left shoulder. The client should be aware to report which symptoms of salicylate toxicity (salicylism)?

A client that the nurse is caring for experiences a seizure. What would be a priority nursing action?

The client had a nasogastric tube placed two days ago. Which nursing action provides the most reliable means to assess placement of a client's nasogastric tube, prior to each medication administration?

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?