Author Question: The nurse caring for a client with a closed head injury gathers the following data: pupils dilated ... (Read 96 times)

naturalchemist · **on:** Jul 22, 2018

The nurse caring for a client with a closed head injury gathers the following data: pupils dilated and nonresponsive bilaterally, no response to vigorous stimuli, absence of corneal reflex, absence of respiratory initiation when carbon dioxide

levels elevate, and decrease in blood pressure. The nurse anticipates a diagnosis of: 1. Increased intracranial pressure.
2. Brain death.
3. Cerebrovascular accident.
4. Intracranial hemorrhage.

Question 2

The nurse is caring for a client with bilateral rales audible in the bases of the lung, jugular vein distention, and a low hematocrit. The nurse attributes these symptoms to which of the following?

1. Fluid volume deficit
2. Fluid volume balance
3. Fluid volume excess
4. Elevated serum calcium and magnesium levels

mcomstock09 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

2
Rationale: This client's condition is highly suspicious of brain death. Further testing will be required to confirm this diagnosis.

Answer to Question 2

3
Rationale: These symptoms are classic manifestations of fluid volume overload or excess causing fluid to shift into the lungs and causing dilution of cells in the hematocrit.