Nokea
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.
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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.
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 in the clinic for a follow-up-visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is a trouble. What action by the nurse is how.
- A. Client who is 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: Personality changes after a traumatic brain injury are common and can be distressing for families. The nurse should prioritize assessing the client with a worsening Glasgow Coma Scale score (from 10 to 8), as this indicates a potential deterioration in neurologic status, which is a medical emergency.
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.
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stening. The clients mental status is deterioration, What action by the nurse is a most appropriate?
- A. Attempt to find the family to sign a consent.
- B. Inform the provider that the procedure cannot occur.
- C. Nothing no consent is needed to an emergency.
- D. Sign the consent form to the client.
Correct Answer: A
Rationale: The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent is life-saving no procedure can be performed without formal consent. The nurse should not just sign the consent form.