This topic contains a solution. Click here to go to the answer

Author Question: A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow ... (Read 74 times)

09madisonrousseau09

  • Hero Member
  • *****
  • Posts: 559
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.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question
Marked as best answer by a Subject Expert

ndhahbi

  • Sr. Member
  • ****
  • Posts: 390
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

  • Member
  • Posts: 559
Reply 2 on: Jun 25, 2018
Wow, this really help


bblaney

  • Member
  • Posts: 323
Reply 3 on: Yesterday
:D TYSM

 

Did you know?

An identified risk factor for osteoporosis is the intake of excessive amounts of vitamin A. Dietary intake of approximately double the recommended daily amount of vitamin A, by women, has been shown to reduce bone mineral density and increase the chances for hip fractures compared with women who consumed the recommended daily amount (or less) of vitamin A.

Did you know?

Medication errors are more common among seriously ill patients than with those with minor conditions.

Did you know?

Signs and symptoms of a drug overdose include losing consciousness, fever or sweating, breathing problems, abnormal pulse, and changes in skin color.

Did you know?

ACTH levels are normally highest in the early morning (between 6 and 8 A.M.) and lowest in the evening (between 6 and 11 P.M.). Therefore, a doctor who suspects abnormal levels looks for low ACTH in the morning and high ACTH in the evening.

Did you know?

Although the Roman numeral for the number 4 has always been taught to have been "IV," according to historians, the ancient Romans probably used "IIII" most of the time. This is partially backed up by the fact that early grandfather clocks displayed IIII for the number 4 instead of IV. Early clockmakers apparently thought that the IIII balanced out the VIII (used for the number 8) on the clock face and that it just looked better.

For a complete list of videos, visit our video library