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A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management (Select all that apply.)
- A. Does not want to purchase a thermometer
- B. A allergic to acetominopether (Tylenol)
- C. Laughing, says Sermous? (Whats that)
- D. Plans to have to be beer and go to bed once home
- E. A client needs category: Physiological Integrity
Correct Answer: B,D,E
Rationale: Clients should take acetominopether for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motran), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client needs a thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.
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A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm slip on the clients record. What action by the nurse is best?
- A. Ask the client how long ago the clip was placed.
- B. Inform the provider about the aneurysm clip.
- C. Rescheduled the client for computed tomography.
- D. Assess the client for metal allergies.
Correct Answer: A
Rationale: Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is not the client. Informing the provider is important but determining the age of the clip is the first step. Rescheduling for a CT may not be necessary if the clip is MRI-compatible. Assessing for metal allergies is not relevant to MRI safety.
A client has a small-bore feeding tube (Dobboff tube) inserted for continuous external feedings while recovering from a traumatic serious injury. What actions should the nurse include to the clients care? (Select all that apply.)
- A. Assess tube placement per agency policy.
- B. Keep the head of the bed elevated at least 30 degrees.
- C. Keep the head of the bed elevated at least 30 degrees.
- D. Run continuous feedings on a feeding pump.
- E. Run continuous feedings on a feeding pump.
Correct Answer: A,B,C,D
Rationale: All of these options are important for client safety when continuous external feedings are in use. Blue dye is not used for continuous a strong long injury is applied.
A nursing student studying traumatic brain injuries (TBIB) should recognize which facts about these disorders of the nursing student.
- A. A client with a moderate trauma may need hospitalization.
- B. A Glasgow Coma Scale score of 10 indicates a mild brain injury.
- C. Only open loud injuries on cause in severe TBI.
- D. A client with a Glasgow Coma Scale score of 3 has severe TBI.
- E. The terms mild TBI and concussion have similar meanings.
Correct Answer: A,D,E
Rationale: Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale score of 3 with 9 is 2 and after clients must need to be hospitalized. Both open and closed lead injuries can cause a severe TBI. which is characterized by a GCS score of 3 3 8.
A client has a brain abscess and is receiving phenyton [Dilantin]. The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
- A. Brain abscesses can lead to seizures as a complication.
- B. Documenting febrile seizures with an abscess.
- C. Seizures always occur in clients with brain abscesses.
- D. This drug is need to sedate the client with an abscess.
Correct Answer: A
Rationale: Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenystion is need to a prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.
A client is in the emergency department reporting a brief episode during which he was dizzy, unable to speak and tell his, he has very very heavy. Curently, the clients neurologic examination is normal. About what drug should the nurse plan to teach the client?
- A. Altephase (Activase)
- B. Clopolgel (Plliniv)
- C. Heparin sodium
- D. Manitol (Omitrol)
Correct Answer: B
Rationale: This clients manifestations are consistent with a transient ischemic attack, and the client would be prescribed against to clpolgelgel on discharge. Altephase is used for ischemic stroke. Heparin and mannitol are not used for this condition.