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The client just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of post procedure care?

"I should drink extra fluids for the remainder of the day"

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

"I will drive only during the day time" (client should not drive b/c device impairs range of vision)

The nurse is caring for a client who has undergone craniotomy with a supratenorial incision. The nurse should plan to place the client in which position postoperatively?

Head of bed elevated 30-45 degrees, head and neck midline. (Keeps pressure off of incision site)

The nurse observes the unlicensed assistive personelle positioning the client with increased inter cranial pressure. Which position would require intervention by the nurse?

Head turned to the side

The nurse is caring for a client with increased inter cranial pressure (ICP). Which change in vital signs would occur if ICP is rising?

Increased temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise.

If you were to give lantus at 2100, when will the insulin begin to work?

Lantus is fast acting. It takes usually 1hr 2200

The client was seen and treated in the ER for a concussion. Before discharge the nurse explains the signs and symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom?

Minor headache

The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time?

The primary health care provider reviews x-ray results (rule out cervical spine injury)

Administering dexamethasone, how would you assess cerebral edema?

Weight. Edema means swelling

If your patient had a stroke and is getting aggravated while you try to reposition them and they become confused, what should you do?

Assess

The client with a cervical spine injury has crutch-field tongs applied in the emergency department. The nurse should perform which essential action when caring for this client?

Comparing the amount of prescribed weights with the amount in use

The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in inter cranial pressure if the nurse observes the client doing which activity?

Exhaling during repositioning

A client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, the nurse should immediately:

Raise the head of the bed and remove the noxious stimulus

The client has clear fluid leaking from her nose after basilar skull fracture. The nurse determines that this is cerebrospinal fluid if the fluid meets which criteria?

Separated into concentric rings and tests positive for glucose

You have a patient who was diagnosed with a stroke who is getting ready to be discharged with a new diuretic, what would you include in the teaching?

check I & O

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which signs/symptoms is noted?

severe, throbbing headache

If your patient has rapid tachycardia, polyphagia, weight loss, which intervention would the nurse prepare for?

give insulin

The client with spinal cord injury is prone to experience autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

limiting bladder catheterization to once every 12 hours (most frequent cause of autonomic dysreflexia is a distended bladder. Catheterization should be q4-6hrs)

The client is having a lumbar puncture performed. The nurse should place the client in which position for this procedure?

side-lying with legs pulled up and chin to chest

A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply.

• padded side rails • an airway at the bed side • oxygen equipment at the bedside • suctioning equipment at the bedside