A nurse is caring for a client who is experiencing Cushing's Triad following a depressed skull fracture. In addition to administering appropriate medications, which of the following nursing interventions should the nurse prioritize for this client?
Encouraging the client to perform deep breathing exercises.
Elevating the head of the bed.
Administering a sedative.
Monitoring intracranial pressure (ICP).
The Correct Answer is D
A. Encouraging deep breathing exercises may help with respiratory function but does not address the immediate risks associated with increased ICP.
B. Elevating the head of the bed can help reduce ICP; however, the priority intervention is to closely monitor ICP to identify any changes in the client's condition.
C. Administering a sedative may be appropriate, but it is not as critical as monitoring ICP in a client with Cushing's Triad, where altered consciousness and respiratory changes may be present.
D. Monitoring ICP is crucial in this situation, as Cushing's Triad indicates a potential increase in ICP, and timely interventions can prevent further complications.
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Correct Answer is A
Explanation
A. Mastoiditis often results in inflammation and infection that extend to the middle ear, causing the tympanic membrane to appear red, dull, thickened, and immobile upon examination.
B. A transparent and clear tympanic membrane is typical in a healthy ear, not in cases of mastoiditis.
C. A pearly colored tympanic membrane is also indicative of a normal, healthy ear without infection.
D. A pink-colored tympanic membrane may suggest mild irritation but is not a characteristic finding of mastoiditis.
Correct Answer is A
Explanation
A. Clients with Cushing’s Syndrome often experience muscle weakness, osteoporosis, and a risk of fractures due to excess cortisol. Implementing fall precautions is the highest priority to prevent injury.
B. Addressing coping mechanisms is important but not as immediate a safety concern as fall prevention.
C. Avoiding infections is crucial due to immunosuppression from elevated cortisol; however, preventing falls remains a more immediate concern.
D. Encouraging incentive spirometer use may support lung function, but it is not the highest priority compared to preventing falls.