A nurse is caring for a client 4 hours following surgical repair of a penetrating brain injury. Which of the following assessments should be the nurse's priority?
Pain level assessment.
Wound site assessment.
Neurological assessment.
Respiratory status assessment.
The Correct Answer is C
A. While pain level assessment is important, it is not the priority immediately after a significant brain injury where neurological changes may occur.
B. Wound site assessment is also essential but does not take precedence over neurological assessment in this context.
C. A neurological assessment is the priority to identify any changes in the client's condition that may indicate complications such as increased intracranial pressure, which can occur after brain surgery.
D. Respiratory status assessment is important but is usually addressed through monitoring and interventions related to neurological function, as brain injuries can affect respiratory drive and function.
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Correct Answer is B
Explanation
A. The Glasgow Coma Scale is useful for assessing consciousness levels but may not be as sensitive for changes in brainstem function in a patient already in an induced coma.
B. Assessing pupillary size and reaction provides critical information on brainstem function and can indicate changes in ICP. Changes in pupil size and reaction can signify worsening cerebral function or brain herniation.
C. Blood pressure and heart rate are vital signs that can suggest increased ICP, but they are not as direct an indicator of cerebral function as pupil assessment.
D. The gag reflex is important but does not provide as direct information about cerebral function related to ICP as pupillary assessment does.
Correct Answer is A
Explanation
A. Chvostek's sign, a facial muscle spasm upon tapping, is a clinical indicator of hypocalcemia, often caused by accidental removal or damage to the parathyroid glands during thyroid surgery.
B. Hypercalcemia does not typically cause a positive Chvostek’s sign.
C. Hypokalemia affects muscle and cardiac function but does not result in a positive Chvostek’s sign.
D. Hyponatremia does not produce Chvostek's sign, which is specific to hypocalcemia.