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 B
Explanation
A. Hormone replacement is generally used to supplement deficiencies rather than inhibit excess hormone release.
B. Dopamine agonists, such as bromocriptine, are used to inhibit the release of growth hormone from the anterior pituitary, which is beneficial in treating acromegaly, a condition caused by excess growth hormone.
C. Levothyroxine is a thyroid hormone replacement and is not effective in controlling pituitary hormone release.
D. Corticosteroids do not inhibit growth hormone release and are typically used to manage inflammation rather than for pituitary hormone control.
Correct Answer is D
Explanation
A. Exophthalmos is typically associated with hyperthyroidism (specifically Graves' disease) rather than hypothyroidism.
B. Diaphoresis (excessive sweating) is also more common in hyperthyroid states, not hypothyroidism.
C. Palpitations are indicative of an increased metabolic rate, which is common in hyperthyroidism; therefore, they would not be expected in a client with hypothyroidism.
D. Lethargy is a classic symptom of hypothyroidism due to decreased metabolism, leading to fatigue and reduced energy levels, making it the expected finding.