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    HESI RN EXIT PROCTORED EXAMQuestion 116
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    HESI RN EXIT PROCTORED EXAM

    Patient data Exhibits Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.

    Explanation & Rationale

    Cerebral edema is the most likely condition the client is experiencing based on the history of submersion, subsequent resuscitation, and the finding of brain edema noted on the head CT scan. Implementing seizure precautions is essential because cerebral edema can increase the risk of seizures. Discontinuing the 0.9% sodium chloride solution IV infusion is necessary because hyponatremia (low serum sodium) is associated with cerebral edema, and reducing fluid intake can help manage cerebral edema. Monitoring strict intake and output is crucial to assess the client's fluid balance and ensure that any changes in fluid status are promptly addressed. Monitoring neurologic status is vital for detecting any changes in consciousness, responsiveness, or neurological function, which could indicate worsening cerebral edema or neurological complications.

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