Which of the following nursing interventions is appropriate
when caring for the awake and oriented head injury patient?
a) Supply oxygen therapy to keep blood gas values within normal
range.
The goal is to keep blood gas values within normal range to ensure
adequate cerebral circulation.
b) Do not elevate the head of the bed.
In general, the head of the bed is elevated about 30 degrees to
decrease intracranial venous pressure.
c) Encourage the patient to cough every 2 hours.
Coughing should not be encouraged because it increases intracranial
pressure.
d) Use restraints if the patient becomes agitated.
Restraints should be avoided because straining against them can
increase intracranial pressure. Use of padded side rails and application
of mitts are the appropriate interventions in the agitated head-injured
patient.

1 Answer

Answer :

a) Supply oxygen therapy to keep blood gas values within normal
range.
The goal is to keep blood gas values within normal range to ensure
adequate cerebral circulation.

Related questions

Description : The most significant nursing problem related to continuous tube feedings is a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of ... in fat metabolism and lipoprotein synthesis Tube feedings maintain fat metabolism and lipoprotein synthesis.

Last Answer : a) potential for aspiration Because the normal swallowing mechanism is bypassed, consideration of the danger of aspiration must be foremost in the mind of the nurse caring for the patient receiving continuous tube feedings.

Description : Which of the following statements reflect nursing interventions of a patient with post-polio syndrome? a) Providing care aimed at slowing the loss of strength and maintaining the physical, ... and cold are most appropriate because these patients tend to have strong reactions to medications.

Last Answer : a) Providing care aimed at slowing the loss of strength and maintaining the physical, psychological and social well being of the patient. No specific medical or surgical treatment is available for ... loss of strength and maintaining the physical, psychological and social well being of the patient.

Description : Which of the following statements reflect nursing interventions in the care of the patient with osteoarthritis? a) Encourage weight loss and an increase in aerobic activity. Weight loss and ... analgesics. Topical analgesics such as capsaicin and methylsalicylate may be used for pain management.

Last Answer : a) Encourage weight loss and an increase in aerobic activity. Weight loss and an increase in aerobic activity such as walking, with special attention to quadriceps strengthening are important approaches to pain management.

Description : During which step of the nursing process does the nurse analyze data related to the patient's health status? a) Assessment Analysis of data is included as part of the assessment. b) ... patient's responses to the nursing interventions and the extent to which the outcomes have been achieved.

Last Answer : a) Assessment Analysis of data is included as part of the assessment.

Description : 100. The client complained of generalized pruritus. The following are appropriate nursing interventions except

Last Answer : B. Regulate the temperature to 25 degrees centigrade or lower

Description : What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the ... oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.

Last Answer : a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen ... literally be pulled away with such great force that they can fly like projectiles towards the magnet.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient with an uncomplicated, mild urinary tract infection (UTI), the nurse knows that recent studies have shown which of the following drugs to be a good choice for ... to be significantly more effective than TMP-SMX in community-based patients and in nursing home residents.

Last Answer : a) Levofloxacin (Levaquin) Levofloxacin, a floroquinolone, is a good choice for short-course therapy of uncomplicated, mild to moderate UTI. Clinical trial data show high patient compliance with the 3-day regimen (95.6%) and a high eradication rate for all pathogens (96.4%).

Description : The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to: a) decrease catabolism. The most important intervention ... the energy source is seen after a burn injury; interventions are instituted to decrease catabolism.

Last Answer : a) decrease catabolism. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%.

Description : If an indwelling catheter is necessary, nursing interventions that should be implemented to prevent infection include a) performing meticulous perineal care daily with soap and water. Cleanliness of the area ... it is clamped because it may cause backflow of urine from the tubing into the bladder.

Last Answer : a) performing meticulous perineal care daily with soap and water. Cleanliness of the area will reduce potential for infection.

Description : Which of the following methods to induce hemostasis after sheath removal post Percutaneous Transluminal Coronary Angioplasty is the least effective? a) Application of a sandbag to the area Several ... ) Application of a pneumatic compression device post PTCA has been demonstrated to be effective

Last Answer : a) Application of a sandbag to the area Several nursing interventions frequently used as part of the standard of care, such as applying a sandbag to the sheath insertion site, have not been shown to be effective in reducing the incidence of bleeding.

Description : The basic difference between nursing diagnoses and collaborative problems is that a) Nurses manage collaborative problems using physician-prescribed interventions. Collaborative problems are physiologic ... or potential health problems that can be managed by independent nursing interventions.

Last Answer : a) Nurses manage collaborative problems using physician-prescribed interventions. Collaborative problems are physiologic complications that nurses monitor to detect onset or changes and manage ... physician-prescribed and nursing-prescribed interventions to minimize the complications of events.

Description : Which of the following categories identifies the focus of community/public health nursing practice? a) Promoting and maintaining the health of populations and preventing and minimizing the progress of ... care delivery Hospice care delivery refers to the delivery of services to the terminally ill.

Last Answer : a) Promoting and maintaining the health of populations and preventing and minimizing the progress of disease Although nursing interventions used by public health nurses might involve individuals, ... , the central focus remains promoting health and preventing disease in the entire community.

Description : 68. The senior asked Marina to list nursing interventions for the nursing diagnosis “Ineffective tissue perfusion: peripheral”. From the following list, which intervention will the senior nurse consider to be contraindicated?

Last Answer : D. Maintain both extremities in a dependent position

Description : Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure Additional signs of increasing ICP ... regarded as unfavorable because hyperthermia may indicate brain stem damage, a poor prognostic sign.

Last Answer : a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.

Description : Which of the following interventions is the single most important aspect for the patient at risk for anaphylaxis? a) Prevention People who have experienced food, medication, idiopathic, or ... alert bracelet will assist those rendering aid to the patient who has experienced an anaphylactic reaction

Last Answer : a) Prevention People who have experienced food, medication, idiopathic, or exerciseinduced anaphylactic reactions should always carry an emergency kit containing epinephrine for injection to prevent the onset of the reaction upon exposure.

Description : Which skill needed by the nurse to think critically involves identification of patient problems indicated by data? a) Analysis Analysis is used to identify patient problems indicated by data. b) ... or interventions used to address patient problems and to help a patient move toward desired outcomes.

Last Answer : a) Analysis Analysis is used to identify patient problems indicated by data.

Description : In order to help prevent the development of an external rotation deformity of the hip in a patient who must remain in bed for any period of time, the most appropriate nursing action would be ... hip replacement surgery. d) a footboard. A footboard will not prevent the hips from rotating externally.

Last Answer : a) a trochanter roll extending from the crest of the ilium to the midthigh. A trochanter roll, properly placed, provides resistance to the external rotation of the hip.

Description : While making your PM shift endorsement, you saw the nursing attendant receiving a package from a patient's watcher. Your appropriate action would be A. Reprimand the nursing attendant right away ... with the nursing attendant the hospital policy D. Endorse to the incoming shift for proper action

Last Answer : D. Endorse to the incoming shift for proper action

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The primary goal towards which the modern school is oriented is that of the development on the parts of its students of Options: A) Adequate behaviour B) Socially acceptable behaviour C) Personal adequacy and independence D) A sound system of ethical values

Last Answer : A) Adequate behaviour

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When caring for the patient in traction, the nurse is guided by which of the following principles? a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the ... are removed routinely. Traction must be continuous to be effective in reducing and immobilizing fractures.

Last Answer : a) Skeletal traction is never interrupted. Skeletal traction is applied directly to the bone and is never interrupted.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

Description : A patient who demonstrates an obtunded level of consciousness a) sleeps almost constantly but can be aroused and can follow simple commands. An obtunded patient stays awake only with persistent ... not respond to environmental stimuli. A comatose patient does not respond to environmental stimuli.

Last Answer : a) sleeps almost constantly but can be aroused and can follow simple commands. An obtunded patient stays awake only with persistent stimulation.

Description : The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in ... severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

Last Answer : a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Description : An osmotic diuretic, such as Mannitol, is given to the patient with increased intracranial pressure (IICP) in order to a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics ... Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

Last Answer : a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

Description : Which of the following actions is most appropriate for the nurse to take when the patient demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest ... finding to the physician immediately. Subcutaneous emphysema results from air entering the tissue planes.

Last Answer : a) Record the observation. Subcutaneous emphysema occurs after chest surgery as the air that is located within the pleural cavity is expelled through the tissue opening created by the surgical procedure.

Description : Which of the following statements are true of a patient with hyperglycemia and hyponatremia? A. The sodium concentration must be corrected by 5 mEq. per 100 mg. per 100 ml. elevation in blood ... . E. Early in treatment adequate urine output is a reliable measure of adequate volume resuscitation.

Last Answer : Answer: D DISCUSSION: Each 100-mg. per 100 ml. elevation in blood glucose causes a fall in serum sodium concentration of approximately 2 mEq. per liter. Excess serum glucose ... correction of the patient's associated acidosis produce movement of potassium ions into the intracellular compartment

Description : Palliation refers to a) relief of symptoms associated with cancer. Palliation is the goal for care in terminal cancer patients. b) hair loss. Alopecia is the term that refers to hair loss. c) ... the lowest point of white blood cell depression after therapy that has toxic effects on the bone marrow.

Last Answer : a) relief of symptoms associated with cancer. Palliation is the goal for care in terminal cancer patients.

Description : For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the ... Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Last Answer : a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless.

Description : Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer's solution Replacement fluids may include isotonic electrolyte solutions and ... only to treat severe symptomatic hyponatremia and should be used only in intensive care units.

Last Answer : a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Description : The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to ... output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Description : A major goal for home care nurses is a) Restoring maximum health function. Tertiary preventive nursing care, focusing on rehabilitation and restoring maximum health function, is a goal for home ... of populations. Maintaining the health of populations is a focus of community/public health nursing.

Last Answer : a) Restoring maximum health function. Tertiary preventive nursing care, focusing on rehabilitation and restoring maximum health function, is a goal for home care nurses.

Description : Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid ... fluid requirements. d) Hypoglycemia Hypoglycemia is not associated with increased fluid requirements.

Last Answer : a) Inhalation injuries Factors associated with increased fluid requirements include inhalation injuries, delayed resuscitation, scald burn injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxification and chronic diuretic therapy.

Description : The nurse teaches the patient with peripheral vascular disease to refrain from smoking because nicotine causes a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the ... the bronchial tree, causing coughing. d) diuresis. Nicotine does not cause diuresis.

Last Answer : a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities.

Description : Which of the following terms refers to an abnormal decrease in white blood cells, red blood cells, and platelets? a) Pancytopenia Pancytopenia may be congenital or acquired. b) Anemia ... of WBCs in circulation. d) Thrombocytopenia Thrombocytopenia refers to a lower-than-normal platelet count.

Last Answer : a) Pancytopenia Pancytopenia may be congenital or acquired.

Description : Which of the following statement(s) is/are true concerning the treatment of MOFS? a. Prevention and therapy of MOFS requires control of the infectious or inflammatory source b. Restoration of normal ... of the nature of gut injury, total parenteral nutrition is preferred for most patients with MOFS

Last Answer : Answer: a, c The therapy of MOFS is directed towards interrupting the involving pathophysiologic process and providing an optimal physiologic environment for healing and recovery. ... Enteral absorption and processing of nutrients appears superior to TPN and lessens overall complications

Description : 70. The senior nurse observes that Marina occasionally does not follow agreed upon interventions. The senior nurse reports that Marina should improve in which of the following?

Last Answer : C. Compliance to standards

Description : A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Last Answer : A. Write and submit an explanation and reprimand as necessary

Description : The term given to the category of triage that refers to lifethreatening or potentially life-threatening injury or illness requiring immediate treatment is a) emergent. The patient triaged as emergent ... . The triage category of immediate refers to non-acute, non-lifethreatening injury or illness.

Last Answer : a) emergent. The patient triaged as emergent must be seen immediately.

Description : Of the following stimuli, which is known to trigger an episode of autonomic hyperreflexia in the patient who has suffered a spinal cord injury? a) Applying a blanket over the patient An ... lower blood pressure. d) Voiding The most common cause of autonomic hyperreflexia is a distended bladder.

Last Answer : a) Applying a blanket over the patient An object on the skin or skin pressure may precipitate an autonomic hyperreflexic episode.

Description : When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Deep partial thickness A deep partial thickness burn is similar to a ... Injury from a flash flame is not associated with a burn that is limited to the epidermis.

Last Answer : a) Deep partial thickness A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames.

Description : The nurse anticipates that the immunosuppressed patient is at greatest risk for which type of shock? a) Septic Septic shock is associated with immunosuppression, extremes of age, ... disease of the heart. d) Anaphylactic Anaphylactic shock is associated with hypersensitivity reactions.

Last Answer : a) Septic Septic shock is associated with immunosuppression, extremes of age, malnourishment, chronic illness, and invasive procedures.

Description : Which of the following statements reflect the nursing management of the patient with a white phosphorus chemical burn? a) Do not apply water to the burn. Water should not be applied to burns from ... from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

Last Answer : a) Do not apply water to the burn. Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn.

Description : Which of the following statements reflects the nursing management of the patient with West Nile Virus infection? There is no treatment for West Nile Virus infection. Patients are supported by fluid replacement ... the virus to animals and humans. There is no human-to-human transmission of virus.

Last Answer : a) The incubation period is three to five days. The incubation period (from mosquito bite until onset of symptoms) is between 5–15 days.

Description : Nursing management of the patient with new variant Creutzfeldt-Jakob Disease (nvCJD) includes a) providing supportive care. The nvCJD is a progressive fatal disease with no treatment available. Due to ... B is used in the treatment of fungal encephalitis; no treatment is available for nvCJD.

Last Answer : a) providing supportive care. The nvCJD is a progressive fatal disease with no treatment available. Due to the fatal outcome of nvCJD, nursing care is primarily supportive.

Description : Which of the following reflects basic nursing measures in the care of the patient with viral encephalitis? a) Providing comfort measures Providing comfort measures directed at the headache, include ... output to alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) Providing comfort measures Providing comfort measures directed at the headache, include dimmed lights, limited noise, and analgesics are the basic nursing measures in the care of the patient with a viral encephalitis.