A patient with head trauma following a motor vehicle accident is ...

[mikaylakyoung]

A patient with head trauma following a motor vehicle accident is on mechanical ventilation with an endotracheal tube. Which action by the nurse will reduce the risk for elevations in intracranial pressure during suctioning?
 
  a. Avoid hyperoxygenating the patient before suctioning.
  b. Insert the suction catheter just to the end of the endotracheal tube.
  c. Apply suction while inserting the catheter.
  d. Limit suctioning to 2 times with each suctioning procedure.

Question 2

A nurse finds a client sitting alone and crying. The most appropriate way to document this is to state:
 
  A. Client appears depressed.
  B. Client sitting alone and appears upset.
  C. Client sitting alone and crying in room, states feels bad when asked.
  D. Client not interacting with others, found obviously upset. Will refer client for evaluation and determination of problem.

[meganmoser117]

Answer to Question 1

D
Suctioning can cause elevations in intracranial pressure in patients with head injury. To reduce the risk, the nurse should hyperoxygenate the patient before suctioning and should suction only twice with each suctioning procedure. The catheter is inserted past the end of the endotracheal tube until resistance is met to adequately remove secretions from the airway. Suction should be applied while the catheter is removed.

Answer to Question 2

C
C. Entries should be concise, factual, and accurate. This is an example of an objective description of a client's behavior.
A and B. The use of vague terms, such as appears, seems, or apparently, is not acceptable because these words suggest that the nurse is stating an opinion.
D. The nurse is making a judgment and stating an opinion. The nurse would not refer the client. This would be the physician's responsibility.

[mikaylakyoung]

TYSM

[Liddy]

Excellent