An unconscious client with multiple injuries arrives in the emergency room. Which nursing intervention receives the highest priority?
Establishing an airway.
Replacing blood loss.
Stopping bleeding from open wounds.
Checking for a neck fracture.
A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor?
Unequal pupil size.
Decreasing systolic blood pressure
Tachycardia.
Decreasing body temperature.
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
Compress the nares.
Tilt the head back.
Give the client a white pad to collect the fluid.
Administer an antihistamine for postnasal drip.
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Slow, irregular respirations.
Rapid, shallow respirations.
Asymmetric chest excursion.
Nasal flaring.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Give the client a warming blanket.
Administer low-dose barbiturates.
Encourage the client to hyperventilate.
Restrict fluids.
client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Widening pulse pressure.
Decrease in the pulse rate.
Dilated, fixed pupil.
Decrease in level of consciousness.
A nurse obtains a specimen of clear nasal drainage from a client with a head injury. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)?
pH.
Specific gravity.
Glucose.
Microorganisms.
The client has a sustained ICP of 20 mm Hg. Which client position would be most appropriate?
The head of the bed elevated 30 to 45 degrees.
Trendelenburg's position.
Left Simm's position.
The head elevated on two pillows.
The nurse administers mannitol (Osmitrol) to the client with increased ICP. Which parameter requires close monitoring?
Muscle relaxation.
Intake and output.
Widening of the pulse pressure.
Pupil dilation.
A male client with a head injury regains consciousness after several days. Which of the following nursing statements is most appropriate as the client awakens?
"I'll get your family."
"Can you tell me your name and where you live?"
"I'll bet you're a little confused right now."
"You are in the hospital. You were in an accident and unconscious."
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her intravenous line. Which nursing intervention protects the client without increasing her ICP?
Place her in a jacket restraint.
Wrap her hands in soft "mitten" restraints.
Tuck her arms and hands under the draw sheet.
Apply a wrist restraint to each arm.
Which activity would the nurse encourage the client to avoid when there is a risk for increased ICP?
Deep breathing.
Turning.
Coughing.
Passive range-of-motion exercises.
Which of the following is most effective in assessing the client suspected of developing diabetes insipidus?
Taking vital signs every 2 hours.
Measuring urine output hourly.
Assessing arterial blood gas values every other day.
Checking blood glucose.
A client who had a serious head injury with increased ICP is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client?
The client will exhibit no further episodes of short-term memory loss.
The client will be able to return to his construction job in 3 weeks.
The client will actively participate in the rehabilitation process as appropriate.
The client will be emotionally stable and display pre-injury personality traits.
Which of the following describes decerebrate posturing?
Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers.
Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of feet.
Supination of arms, dorsiflexion of the feet.
Back arched, rigid extension of all four extremities.
client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Count the rate to be sure that ventilations are deep enough to be sufficient.
Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma Scale score.
Call the physician to adjust the ventilator settings.
Check deep tendon reflexes to determine the best motor response.
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?