NCLEX book The client with a Head injury

2. Elevate the head of the bed 15 to 20 degrees. 3. Contact the healthcare provider (HCP) if ICP is >15 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale.

1. The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply. 1. Encourage the client to cough to expectorate secretions. 2. Elevate the head of the bed 15 to 20 degrees. 3. Contact the healthcare provider (HCP) if ICP is >15 mm Hg. 4. Monitor neurologic status using the Glasgow Coma Scale. 5. Stimulate the client with active range-of- motion exercises.

1. slow, irregular respirations

10. Which respiratory pattern indicates increasing intracranial pressure in the brain stem? 1. slow, irregular respirations 2. rapid, shallow respirations 3. asymmetric chest excursion 4. nasal flaring

3. encourage the client to take deep breaths to hyperventilate.

11. A client has an increased intracranial pressure (ICP) of 20 mm Hg. The nurse should: 1. give the client a warming blanket. 2. administer low-dose barbiturates. 3. encourage the client to take deep breaths to hyperventilate. 4. restrict fluids.

4. decrease in level of consciousness (LOC)

12, The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the healthcare provider (HCP) about which early change in the client's condition? 1. Widening pulse pressure 2. Decrease in the pulse rate 3. Dilated, fixed pupils 4. Decrease in level of consciousness (LOC)

1. the head of the bed elevated 15 to 20 degrees

13. The client has a sustained increased intracranial pressure (ICP) of 20 mm Hg. Which client position would be most appropriate? 1. the head of the bed elevated 15 to 20 degrees 2. Trendelenburg's position 3. left Sims' position 4. the head elevated on two pillows

2. intake and output

14. The nurse administers mannitol to the client with increased intracranial pressure. Which parameter requires close monitoring? 1. muscle relaxation 2. intake and output 3. widening of the pulse pressure 4. pupil dilation

4. the client's hand-grasp strength is equal.

15. The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document that: 1. the client's shoulders shrug against downward pressure of the examiner's hands. 2. the client's arm pulls up from a resting position against resistance. 3. the client's arm straightens out from a flexed position against resistance. 4. the client's hand-grasp strength is equal.

2. Wrap the hands in soft "mitten" restraints.

16. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. Which nursing intervention protects the client without increasing the intracranial pressure (ICP)? 1. Place the client in a jacket restraint. 2. Wrap the hands in soft "mitten" restraints. 3. Tuck the arms and hands under the sheet. 4. Apply a wrist restraint to each arm.

3. coughing

17. Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)? 1. deep breathing 2. turning 3. coughing 4. passive range-of-motion (ROM) exercises

3. actively participate in the rehabilitation process as appropriate.

18. A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which outcome of rehabilitation would be appropriate for the client? The client will: 1. exhibit no further episodes of short-term memory loss. 2. be able to return to his construction job in 3 weeks. 3. actively participate in the rehabilitation process as appropriate. 4. be emotionally stable and display preinjury personality traits.

4. back arched and rigid extension of all four extremities.

19. The nurse is assessing a client for decerebrate posturing. The nurse should assess the client for: 1. internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. 2. back hunched over and rigid flexion of all four extremities with supination of arms and plantar flexion of feet. 3. supination of arms and dorsiflexion of the feet. 4. back arched and rigid extension of all four extremities.

1. systolic blood pressure 4. cerebral perfusion pressure

2. The nurse is monitoring a client with increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply. 1. systolic blood pressure 2. urine output 3. breath sounds 4. cerebral perfusion pressure 5. level of pain

2. Notify the healthcare provider (HCP) of the client's breathing pattern.

20. A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do? 1. Count the rate to be sure that ventilations are deep enough to be sufficient. 2. Notify the healthcare provider (HCP) of the client's breathing pattern. 3. Increase the rate of ventilations. 4. Increase the tidal volume on the ventilator.

2. elevating the head of the bed to 30 degrees

21. The nurse is planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. What should the nurse avoid when positioning the client? 1. keeping the client flat on one side or the other 2. elevating the head of the bed to 30 degrees 3. logrolling or turning as a unit when turning 4. keeping the neck in a neutral position

3. bradycardia 4. widening pulse pressure

22. A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temperature 99°F (37°C), pulse 100 bpm, respirations 18 breaths/min, and BP 140/70 mm Hg. The nurse should report which changes should they occur to the healthcare provider (HCP)? Select all that apply. 1. decreasing urinary output 2. decreasing systolic BP 3. bradycardia 4. widening pulse pressure 5. tachycardia 6. increasing diastolic BP

4. "You are in the hospital. You were in an accident and unconscious."

23. A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client? 1. "I will get your family.' 2. "Can you tell me your name and where you live?" 3. "I will bet you are a little confused right now.' 4. "You are in the hospital. You were in an accident and unconscious."

80 mmHg

3. A nurse is assessing a client with increasing intracranial pressure. What is a client's mean arterial pressure (MAP) in mm Hg when blood pressure (BP) is 120/60 mm Hg?

3. Chart the client's level of consciousness as coma.

5. The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do? 1. Attempt to arouse the client. 2. Reposition the client with the extremities in normal alignment 3. Chart the client's level of consciousness as coma 4. Notify the healthcare provider

1. Establish an airway.

6. An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? 1. Establish an airway 2. Determine the identity of the client 3. Stop bleeding from open wounds 4. Check for a neck fracture

4. Approach the client using short sentences. 3. Assure the client's safety 2. Maintain a quiet environment 1. Request a prescription for haloperidol

7. A client has delirium following a head injury. The client is disoriented and agitated. In which order from first to last should the nurse initiate care for this client? All options must be used. 1. Request a prescription for haloperidol. 2. Maintain a quiet environment. 3. Assure the client's safety. 4. Approach the client using short sentences.

1. unequal pupil size

8. A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? 1. unequal pupil size 2. decreasing systolic blood pressure 3. tachycardia 4. decreasing body temperature

3. Collect the drainage.

9. What should the nurse do first when a client with a head injury begins to have clear drainage from the nose? 1. Compress the nares. 2. Tilt the head back. 3. Collect the drainage. 4. Administer an antihistamine for postnasal drip.