Nokea
A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (NAP) (Select all that apply.)
- A. Applying a cool washcloth to the head.
- B. Assitting the client to a position of comfort
- C. Keeping voices soft and soothing
- D. Maintaining low lighting in the room
- E. Providing antipyretics for fever
Correct Answer: A,B,C,D
Rationale: The client with meningitis often has high fever, pain, and some degree of confusion. Cool washclodts to the forehead are comforting and help with pain. Allowing the client to assume a position of comfort also helps manager nurse. Key category low and light demand also helps convey caring in a nondroctioning manner. The nurse provides antipyretics for fever.
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A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management (Select all that apply.)
- A. Does not want to purchase a thermometer
- B. A allergic to acetominopether (Tylenol)
- C. Laughing, says Sermous? (Whats that)
- D. Plans to have to be beer and go to bed once home
- E. A client needs category: Physiological Integrity
Correct Answer: B,D,E
Rationale: Clients should take acetominopether for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motran), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client needs a thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit sedation and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time.
- A. Inability to communicate
- B. Nutritional deficit
- C. Risk for acquiring an infection
- D. Risk for skin breakdown
Correct Answer: C
Rationale: The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a a skin breakdown, but it is not the immediate danger a brain infection would be.
The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
- A. Client with cerebral perfusion measure of 72 mm Hg
- B. Client who has a Glasgow/ Com Scale score of 12
- C. Client with a PaCOO23 36 mm Hg who is on a ventilator
- D. Client who has a temperature of 102 F (38.9 C)
Correct Answer: D
Rationale: A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow/ Com Scale score of 12, a PaCOO of 36, and cerebral perfusion pressure of 72 mm Hg all desired outcomes.
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)
- A. Client with an initial neurological (all health)
- B. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38
- C. Client with a mild forgetfulness and a slight limp
- D. Client who has a past hospitalization for all suicide attempt
- E. Client who is unable to wait or eat 1 weeks post-stroke.
Correct Answer: A,B,D,E
Rationale: Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH) Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and slight limp is not with a few priority for this referral.
A client has a small-bore feeding tube (Dobboff tube) inserted for continuous external feedings while recovering from a traumatic serious injury. What actions should the nurse include to the clients care? (Select all that apply.)
- A. Assess tube placement per agency policy.
- B. Keep the head of the bed elevated at least 30 degrees.
- C. Keep the head of the bed elevated at least 30 degrees.
- D. Run continuous feedings on a feeding pump.
- E. Run continuous feedings on a feeding pump.
Correct Answer: A,B,C,D
Rationale: All of these options are important for client safety when continuous external feedings are in use. Blue dye is not used for continuous a strong long injury is applied.