Nokea
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- A. Maintain the head of the bed at 60 degrees of elevation.
- B. Administer stool softeners daily.
- C. Ensure the pulse oximeter reading is higher than 93%.
- D. Perform deep nasal suction every two (2) hours.
- E. Administer mild sedatives.
Correct Answer: B,C
Rationale: Stool softeners (B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (C) ensures adequate oxygenation. High HOB elevation (A) may reduce cerebral perfusion, deep suction (D) risks increasing ICP, and sedatives (E) may mask neurological changes.
You may also like to solve these questions
A hospitalized client diagnosed with seizures has a vagus nerve stimulation (VNS) device implanted. The nurse determines that the VNS is working properly when making which observation?
- A. It stimulated a heartbeat when bradycardia occurred during a seizure.
- B. It defibrillated a lethal rhythm that occurred during the client’s seizure.
- C. The client activates the VNS device to stop a seizure from occurring.
- D. The client activates the device at seizure onset to prevent aspiration.
Correct Answer: C
Rationale: A VNS device does not stimulate the heart to beat as a pacemaker. A VNS device does not defibrillate the heart as an implantable cardioverter/defibrillator does. A VNS is a medical device that is implanted in the chest and stimulates the vagus nerve to control seizures unresponsive to medical treatment. Clients who experience auras before a seizure use a magnet to activate the VNS to stop the seizure. The device does not have an effect on the airway or secretions.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
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 scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt-Jakob disease. Which intervention should the nurse implement prior to the procedure?
- A. Determine if the client has claustrophobia.
- B. Obtain a signed informed consent form.
- C. Determine if the client is allergic to egg yolks.
- D. Start an intravenous line in both hands.
Correct Answer: A
Rationale: MRI involves a confined space, so assessing for claustrophobia (A) ensures patient comfort and safety. Consent (B) is required but secondary, egg yolk allergy (C) is irrelevant, and bilateral IVs (D) are unnecessary.
The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.