Reference no: EM133876729

Question

1. The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's eripheral response to pain

a. Sternal rub b. Nailbed pressure c. Pressure on the orbital rin d. Squeezing of the sternocleidomastoid muscle

2. The nurse is caring for the client with increased ICP as a result of a head injury. The nurse would note which trend in vital signs if the ICP is rising?

3. A client recovering from a head injury is participating in care. The nurse determines that the client understand measures to prevent elevations in ICP if the nurse observes the client doing what?

4. A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that CSF is fluid?

5. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which which measures in the plan of care to minimize the risk of occurrence? SATA

a. Keeping linens wrinkle-free under the client b. Preventing unnecessary pressure on the lower limbs c. Limiting bladder catheterization to once every 12 hours d. Turning and repositioning the client at least every 2 hours e. Ensuring the client has a bowel movement at least once a week Vain haun A unlanke Inf+ Unlock document