Nokea
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
- A. Dextrose 5% in water (D5W)
- B. Half-normal saline (0.45% NSS)
- C. One-third normal saline (0.33% NSS)
- D. Lactated Ringer's
Correct Answer: D
Rationale: With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
You may also like to solve these questions
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?
- A. Sleep pattern
- B. Mood and affect
- C. Appetite
- D. Muscle spasms
Correct Answer: D
Rationale: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
- A. The client will take the seizure medication at the same time daily.
- B. The client will remain free of injury if a seizure does occur.
- C. The client will verbalize an understanding of feelings that preempt seizure activity.
- D. The client will post emergency numbers on the refrigerator for ease of obtaining.
Correct Answer: B
Rationale: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
A client the nurse is caring for experiences a seizure. What would be a priority nursing action?
- A. Restrain the client during the seizure.
- B. Insert a tongue blade between the teeth.
- C. Protect the client from injury.
- D. Suction the mouth during the convulsion.
Correct Answer: C
Rationale: The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.
The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?
- A. Increased intracranial pressure
- B. Decreased intracranial pressure
- C. Hypervolemia
- D. Hypovolemia
Correct Answer: A
Rationale: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that fluid volume either increasing or decreasing is an issue.
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
- A. Insert an airway or bite block.
- B. Manually restrain the extremities.
- C. Turn client to side-lying position.
- D. Monitor vital signs.
Correct Answer: C
Rationale: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase.