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A nurse cares for older clients who have traumatic brain injury. What should be nurse understand about this population? (Select all that apply.)
- A. A client with a moderate brain injury. nursing mechanisms for older clients.
- B. Alcohol is typically involved a more traumatic brain injuries for this age group.
- C. These clients are more susceptible to systemic and wound infections.
- D. A client with a moderate brain injury. nursing mechanisms for older clients.
- E. Very few traumatic brain injuries occur in this age group.
Correct Answer: A,C,D
Rationale: Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and more because of decreased protective mechanisms. they are more susceptible to both older and systemic injuries. A moderate brain injuries are more susceptible to older and more susceptible to older and more related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.
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A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the de/ocate sodium (Col/ace) because the client had a large stool car/ifier. What action by the supervising nurse is best?
- A. Have the student ask the client if it is desired or not.
- B. Infer the the student that the de/ocate should be given.
- C. Tell the student to document the ration/ale.
- D. Tell the student to give it unless the client refuses.
Correct Answer: B
Rationale: A student nurse should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Val/aba's maneuver when cons/ist/ated. The supervising nurse should instruct the student to administer the docuscate. The other options are not appropriate. The medication could be held for diarrhea.
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm slip on the clients record. What action by the nurse is best?
- A. Ask the client how long ago the clip was placed.
- B. Inform the provider about the aneurysm clip.
- C. Rescheduled the client for computed tomography.
- D. Assess the client for metal allergies.
Correct Answer: A
Rationale: Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is not the client. Informing the provider is important but determining the age of the clip is the first step. Rescheduling for a CT may not be necessary if the clip is MRI-compatible. Assessing for metal allergies is not relevant to MRI safety.
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 nurse is caring for a client after a stroke. What actions may the nurse delegate to the unlicensed assistive person and (UAP)? (Select all that apply.)
- A. Assess neurologic status with the Glasgow Coma Scale.
- B. Check and document oxygen saturation every 1 to 2 hours.
- C. Check and document oxygen saturation every 1 to 2 hours.
- D. Elevate the head of the bed to 45 degrees to prevent aspiration.
- E. Elevate the head of the bed to 45 degrees to prevent aspiration.
Correct Answer: B,E
Rationale: The UAP can take and document vital signs, including oxygen saturation, and keep the clients head in a neutral midline position with correct direction from the nurse. The nurse assesses the Glasgow Coma Scale score. The nursing staff should not cluster care because this can cause an increase in the intracranial pressure. The head of the bed should be minimally elevated, up to 30 degrees.
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.