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A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
- A. Administer a stool softener bid.
- B. Encourage the client to cough hourly.
- C. Monitor neurological status every shift.
- D. Maintain the dopamine drip to keep BP at 160/90.
Correct Answer: A
Rationale: Post-craniotomy for subarachnoid hemorrhage, preventing increased intracranial pressure is critical. A stool softener (A) prevents straining, which could raise ICP. Coughing (B) increases ICP, neurological checks (C) should be more frequent (e.g., hourly), and dopamine to maintain high BP (D) risks re-bleeding.
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Which discharge teaching is essential for a client with a spinal cord injury to prevent respiratory complications?
- A. Perform deep breathing exercises daily.
- B. Avoid outdoor activities.
- C. Limit fluid intake to reduce secretions.
- D. Sleep in a prone position.
Correct Answer: A
Rationale: Deep breathing exercises help prevent atelectasis and pneumonia in clients with spinal cord injuries.
The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
- A. Change in pupil size and reaction
- B. Sudden drop in the blood pressure
- C. Experiencing diminished sensation
- D. Change in the level of consciousness
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.
The client is being discharged following a transsphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client? Select all that apply.
- A. Sleep with the head of the bed elevated.
- B. Keep a humidifier in the room.
- C. Use caution when performing oral care.
- D. Stay on a full liquid diet until seen by the HCP.
- E. Notify the HCP if developing a cold or fever.
Correct Answer: A,C,E
Rationale: Elevating the HOB (A) reduces ICP, cautious oral care (C) prevents surgical site disruption, and reporting infections (E) is critical due to infection risk. Humidifiers (B) are not standard, and a liquid diet (D) is unnecessary unless specified.
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
- A. Obtain a rubber mat to place under the dinner plate.
- B. Purchase a long-handled bath sponge for showering.
- C. Purchase clothes with Velcro closure devices.
- D. Obtain a raised toilet seat for the client's bathroom.
Correct Answer: B,C,D
Rationale: Generalized weakness post-stroke affects mobility and self-care. A long-handled bath sponge (B) aids bathing, Velcro clothes (C) simplify dressing, and a raised toilet seat (D) facilitates safe toileting. A rubber mat (A) is less relevant to generalized weakness.
During the immediate postoperative assessment, the nurse notices the dressing is moist. Which action is most appropriate to take first?
- A. Change the dressing.
- B. Reinforce the dressing.
- C. Remove the dressing.
- D. Document the findings.
Correct Answer: B
Rationale: Reinforcing the dressing controls minor drainage and maintains sterility while further assessment is conducted.