Kaplan Question Bank

[KaKujak0980]

This is the question..is this a mistake? The answer #3 seems contradictory and not something you should be doing with someone with ICP. And #4 even says do not administer morphine. Do you all think it is a typo or am I missing something? Thanks for your help!!

The client is admitted to the emergency department (ED) after a motor vehicle accident. The client does not remember the accident. The client is awake and oriented to person, but does not know what city he is in. He is confused regarding the day and the month. Pupils are equal in size and equally reactive to direct light. The client reports a severe headache and becomes restless. Which action should the nurse take first?

[TABLE=class: interaction]

[TR=class: answerChoiceRow]

[TD][/TD]

[TD]1. [/TD]

[TD=class: choiceContent]Continue to stimulate the client to keep oriented to the surroundings.[/TD]

[/TR]

[TR=class: answerChoiceRow]

[TD][/TD]

[TD]2. [/TD]

[TD=class: choiceContent]Restrain the client to prevent injuring themself.[/TD]

[/TR]

[TR=class: answerChoiceRow]

[TD][/TD]

[TD]3. [/TD]

[TD=class: choiceContent]Administer morphine.[/TD]

[/TR]

[TR=class: answerChoiceRow]

[TD][/TD]

[TD]4. [/TD]

[TD=class: choiceContent]Administer meperidine hydrochloride (Demerol). [/TD]

[/TR]

[/TABLE]

Strategy: Assess before implementing.1) assess before implementing2) must use the least restrictive method to keep client safe; assess before implementing3) CORRECT— may be developing increased intracranial pressure (ICP); confusion, restlessness, pupillary changes, and altered level of consciousness are earliest signs of ICP 4) do not administer morphine, may mask signs of ICP