Question

The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate action?

Answer 1

The nurse should monitor the patient, assess neurological status, provide oxygen as needed, and promptly report changes to the medical team for a client with increased respiratory effort after head injury. Additional tests like chest radiography and sampling of blood, urine, and sputum might be performed depending on the assessment.

Step-by-step explanation:

The nurse's most appropriate action when caring for a client with a moderate head injury who shows an increased respiratory effort would be to continuously monitor the patient, assess the neurological status, provide oxygen as required, and promptly report the changes in respiration to the attending physician or medical team. An increased respiratory effort may indicate a decline in neurological status or other complications. Therefore, a rapid assessment and appropriate response are critical. Documenting and communicating the client's condition is an integral part of the nursing care and aligns with the nurse's responsibility to ensure patient safety.

Given the client's symptoms and consultation with a physician, additional assessments, such as a Chest radiography, and collection of blood, urine, and sputum samples might be considered to rule out other complications or infections like influenza or pneumonia. In an emergency setting where a client presents a change in respiratory pattern or neurological function, it is crucial to perform a rapid neurological assessment due to the importance of early detection and treatment of potentially life-threatening conditions.