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.
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Related Questions
Correct Answer is B
Explanation
Impaired Gas Exchange. Impaired gas exchange is the greatest concern in the immediate postoperative period for a client recovering from bariatric surgery, as the client may have difficulty breathing due to anesthesia, pain medication, or obesity-related respiratory problems.
Option A, Impaired Mobility, is a concern but not the greatest concern in the immediate postoperative period.
Option C, Self-Care Deficit, may be an issue but is not the greatest concern in the immediate postoperative period.
Option D, Diarrhea, may occur after bariatric surgery but is not the greatest concern in the immediate postoperative period.
Correct Answer is D
Explanation
A blood glucose reading of 48 is considered low and requires immediate intervention to raise the client's blood sugar. Intravenous dextrose solution is the fastest way to raise blood sugar levels in an unconscious client. Glucagon and cortisone can also be used to raise blood sugar levels, but they are not the first-line treatment for hypoglycemia.
Choice A, orange juice, is not appropriate for an unconscious client as they cannot swallow or drink.
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