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A client is the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
- A. Ensure that informed consent is on the chart
- B. Document these findings in the client record.
- C. Give the prescribed/prorecedure/relation.
- D. Notify the provider of the findings immediately.
Correct Answer: D
Rationale: This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead is hesitation. Informed consent is needed for an LP. but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure/relation (or other preprocedure/mediations) should not be given as the LP will most likely be canceled.
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A nursing student studying the neurologic system learns which information? (Select all that apply.)
- A. An aneurysm is a ballooning in a weakened part of an arterial wall.
- B. An arteriovenous malformation is the usual cause of the stroke.
- C. Intracerebral hemorrhage is bleeding directly into the brain.
- D. Reduced perfusion from vasospasm often makes stroke worse.
- E. Subarachnoid hemorrhage is caused by high blood pressure.
Correct Answer: A,C,D
Rationale: An aneurysm is a ballooning of the weakened part of an arterial wall. Intracerebral hemorrhage is bleeding directly into the brain. Vasospasm often makes the damage from the initial stroke worse because it causes decreased perfusion. An arteriovenous malformation (AVM) is unusual. Subbranchoid hemorrhage is usually caused by a ruptured aneurysm or AVM.
A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-PA, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) mL/hr
- A. 1.2 mL/hr
- B. 1.4 mL/hr
- C. 1.6 mL/hr
- D. 1.8 mL/hr
Correct Answer: B
Rationale: The client weighs 225 pounds, which is approximately 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the client's dose is 90 mg. 10% of the dose (9 mg) is given as a bolus IV over the first minute, leaving 81 mg to be infused over 60 minutes. Therefore, 81 mg ÷ 60 min = 1.35 mg/min, which rounds to 1.4 mL/hr.
After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 m/mr. What action by the nurse is best?
- A. Assess the client needs care.
- B. Assess the clients sodium level.
- C. Increase the rate of the IV infusion.
- D. Provide the care every hour.
Correct Answer: B
Rationale: This client has manifestations of hypermatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessment/inursing records.
A nursing student studying traumatic brain injuries (TBIB) should recognize which facts about these disorders of the nursing student.
- A. A client with a moderate trauma may need hospitalization.
- B. A Glasgow Coma Scale score of 10 indicates a mild brain injury.
- C. Only open loud injuries on cause in severe TBI.
- D. A client with a Glasgow Coma Scale score of 3 has severe TBI.
- E. The terms mild TBI and concussion have similar meanings.
Correct Answer: A,D,E
Rationale: Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale score of 3 with 9 is 2 and after clients must need to be hospitalized. Both open and closed lead injuries can cause a severe TBI. which is characterized by a GCS score of 3 3 8.
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.