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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.
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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 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.
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.
The nurse working in the emergency department assesses a client who has symptoms of stroke. For what modifiable risk factors should the nurse assess? (Select all that apply.)
- A. Alcohol intake.
- B. Alcohol intake.
- C. High-fat diet.
- D. Obesity.
- E. Smoking.
Correct Answer: A,C,D,E
Rationale: An alcohol intake a high-fat diet. obesity, and smoking are all modifiable risk factors for stroke. Diabetes is not modifiable but is a risk factor that can be controlled with medical intervention.
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)
- A. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence.
- B. Client who had a cool procedure who says that there will be no problem following up for 1 year.
- C. Client who underwent a flow diversion procedure 3 months ago who is taking discontinue sodium (Colace) for constipation.
- D. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
Correct Answer: A,B
Rationale: After a coil procedure, up to 20% of clients experience re-beding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.