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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Abandon biases that older adults are sexually inactive. Older adults are sexually active and at risk for sexually transmitted infections (STIs). The nurse should not make assumptions about the client's sexual activity based on age.
Option A, older clients who are sexually active have less risk for STIs than other age groups, is incorrect because older adults are at risk for STIs. Option C, older clients know the ways to prevent STIs, may not always be accurate.
Option D, older clients, because of their maturity, are rarely embarrassed to talk about it, is a generalization and may not be true for all older clients.
Correct Answer is A
Explanation
Through the application of extreme cold, the tissue is destroyed. Cryosurgery is a procedure that uses extreme cold to destroy abnormal tissues, including tumors and growths. Extreme cold is applied directly to the affected area, and this damages the cells and causes them to die. The destroyed tissue is then gradually absorbed by the body's natural healing processes. Therefore, the correct response to the client's question is that cryosurgery destroys the tissue through the application of extreme cold.
B is not the correct answer because laser surgery uses heat to destroy the tissue, not extreme cold.
C is not the correct answer because cryosurgery does not necessarily remove the entire growth.
D is not the correct answer because cryosurgery freezes the growth and destroys it, not freezes it for removal at a later time.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.