A newly admitted client with increased intracranial pressure ...

[09madisonrousseau09]

A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS) score of 6.
 
  Which action by the nurse is the most appropriate?
  A) Assess airway, breathing, and circulation.
  B) Assess patency of the Foley catheter.
  C) Treat the client's pain.
  D) Get a complete history from the client.

Question 2

A client is admitted with airway edema, bronchoconstriction, and increased mucus production after being exposed to an allergen. Which nursing interventions are appropriate to address this inflammation to the respiratory system?
 
  Select all that apply.
  A) Turn and reposition every 2 hours.
  B) Monitor oxygen saturation.
  C) Administer oxygen as prescribed.
  D) Restrict fluids.
  E) Monitor lung sounds.

[ndhahbi]

Answer to Question 1

Answer: A

The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness. A score of 15 indicates full alertness and a score of 8 or less is usually indicative of coma; the lowest possible score is 3. The client's score is low so the nurse should follow the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and assessing the patency of the Foley catheter are done only after the airway is clear and the client is breathing.

Answer to Question 2

Answer: B, C, E

Turning and repositioning every 2 hours would be appropriate to maintain tissue integrity. Monitoring oxygen saturation, administering oxygen, and monitoring lung sounds would be appropriate care for the client with inflammation to the respiratory system. Restricting fluids could cause respiratory secretions to thicken and hinder the client's ability to maintain a clear airway. Fluids should be encouraged.

[09madisonrousseau09]

Gracias!

[amit]

TYSM