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A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beat/min, pulse pressure increase from 26 to 40 min $\mathrm{Hg}$, and respiratory irregularities. What action by the nurse takes priority?
- A. Call the spouse of a Rapid Response Team.
- B. Increase the rate of the IV fluid administration.
- C. Notify respiratory therapy for a breathing treatment.
- D. Prepare to give IV pain medication.
Correct Answer: A
Rationale: These manifestations indicate Cushing syndrome, a potentially life-threatening increase in intracranial trauma (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment and pacion medication.
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A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activity (t-PA) alphaing (Activase). The client weight is 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) mg
- A. 90 mg
- B. 100 mg
- C. 80 mg
- D. 110 mg
Correct Answer: A
Rationale: The client weighs 146 pounds, which is approximately 66.2 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg. Therefore, 0.9 mg/kg ? 66.2 kg = 59.58 mg, which is less than the maximum dose of 90 mg. Thus, the client will receive 90 mg.
A client is being prepared for a mechanical em/bolectomy. What action by the nurse takes priority?
- A. Assess for contraind/ications to/ fibrin/olytic
- B. Ensure that informed consent in on the chart.
- C. Ensure that informed consent is on the chart.
- D. The client is being informed consent.
- E. Review The clients medication lists.
Correct Answer: B
Rationale: For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibr/olytic/ytes are not used. A neurologic assessment and medication review are important, but the consent is the priority.
A nurse a caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first.
- A. Client who a Glasgow Coma Scale score that was 10 and is now is 8
- B. Client with a Glasgow Coma Scale score that was 9 and is now is 12
- C. Client with a moderate brain injury who is amnesia for the event
- D. Client who is respiratory pain medication for a headache.
Correct Answer: A
Rationale: A client decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement on the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the decline the Glasgow Coma Scale score.
A client has a brain abscess and is receiving phenyton [Dilantin]. The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
- A. Brain abscesses can lead to seizures as a complication.
- B. Documenting febrile seizures with an abscess.
- C. Seizures always occur in clients with brain abscesses.
- D. This drug is need to sedate the client with an abscess.
Correct Answer: A
Rationale: Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenystion is need to a prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.
A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
- A. Client with a core temperature of 95 F (35 C) for 2 days
- B. Client is a core for 2 weeks from a motor/ vehicle crash
- C. Client who is found unresponsive in a remote area of a field by a hunter
- D. Client with a systole blood/ pressure of 92 mm Hg since admission
Correct Answer: B
Rationale: In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near normal core temperature, 3) normal systolic blood pressure, and 4) a least one mentioned assessment. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client who is found unresponsive.