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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is A
Explanation
A. In SIADH, excess ADH causes water retention and hyponatremia; fluid restriction helps to prevent further dilution of sodium and manage fluid balance.
B. NPO status is unnecessary unless otherwise indicated; managing fluid intake is more effective.
C. Increasing oral intake would worsen fluid overload and hyponatremia.
D. Rapid IV fluid infusion can exacerbate the client’s condition by increasing fluid volume further.
Correct Answer is ["A","B","C","D"]
Explanation
A. Reducing body weight can relieve pressure on the lumbar spine, which can help decrease pain and improve function.
B. Avoiding painful positions helps prevent exacerbation of symptoms and protects the affected area.
C. Physical therapy is an important part of conservative treatment to strengthen supporting muscles, improve flexibility, and promote recovery. Chiropractic therapy may be recommended but should be guided by a physician's recommendation.
D. NSAIDs are commonly prescribed to manage inflammation and relieve pain associated with lumbar herniated disks.
E. Corticosteroids may be prescribed in some cases but are generally not part of initial conservative management unless inflammation is severe and not managed by NSAIDs.