The nurse is caring for a client who sustained a head injury in a motor vehicle accident and is diagnosed with a subdural hematoma and increased intracranial pressure. Which nursing intervention is appropriate for this client?
Keeping the room brightly lit.
Encouraging coughing and deep breathing exercises.
Placing the client in a supine position.
Implementing seizure precautions.
The Correct Answer is D
A. Keeping the room brightly lit can be overstimulating and may increase ICP; therefore, a calm, dimly lit environment is preferable.
B. Encouraging coughing and deep breathing exercises could increase ICP and should be avoided unless specifically indicated.
C. Placing the client in a supine position is not recommended for clients with increased ICP; they should typically be positioned with the head elevated to promote venous drainage.
D. Implementing seizure precautions is critical as head injuries can lead to seizures, and ensuring the client's safety is a priority.
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Correct Answer is ["A","B","D"]
Explanation
A. Hypertension can occur due to autonomic dysreflexia, especially in clients with cervical spinal cord injuries, as they may have exaggerated sympathetic responses.
B. A weakened gag reflex can result from cranial nerve involvement due to the cervical spinal cord injury, impacting the client's ability to protect their airway.
C. Absence of bowel sounds may indicate bowel immobility or dysfunction; however, it is not a direct complication of a cervical spinal cord injury.
D. Bradycardia is a common finding in cervical spinal cord injuries due to impaired sympathetic nervous system function, leading to decreased heart rate.
E. Tachycardia is less common in cervical injuries and is typically associated with lower injuries in the spinal cord.
Correct Answer is B
Explanation
A. Weight gain is not typical in Addison's disease; instead, weight loss is common.
B. Hyperpigmentation, particularly in sun-exposed areas and skin folds, is a classic symptom of Addison's disease due to elevated ACTH levels.
C. Low blood pressure, not elevated, is common due to decreased cortisol levels.
D. Purple striations are more commonly seen in Cushing's syndrome rather than Addison's disease.