A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The…

The correct answer is C. Return to the hospital immediately if he develops confusion, nausea, or vomiting. (A) Povidone-iodine is very irritating to skin and should not be routinely used. (B) Sutures should not be removed by the client. (C) Confusion, nausea, vomiting, and behavioral changes may indicate increasing intracranial pressure as a result of intracerebral bleeding. (D) Use…

Physiological Integrity: Reduction of Risk Potential

Question

A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurseinstructs the client to:

Options

AClean the sutured laceration twice a day with povidone- iodine (Betadine)
BRemove his scalp sutures after 5 days
CReturn to the hospital immediately if he develops confusion, nausea, or vomiting
DTake meperidine 50 mg po q4-6h prn for headache

How the community answered

(26 responses)

A
8% (2)
C
88% (23)
D
4% (1)

Explanation

(A) Povidone-iodine is very irritating to skin and should not be routinely used. (B) Sutures should not be removed by the client. (C) Confusion, nausea, vomiting, and behavioral changes may indicate increasing intracranial pressure as a result of intracerebral bleeding. (D) Use of a narcotic opiate such as meperidine is not recommended in clients with a possible head injury because it may produce sedation, pupil changes, euphoria, and respiratory depression, which may mask the signs of increasing intracranial pressure.

Topics

#head injury#increased ICP#discharge teaching#neurological warning signs

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