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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.
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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 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 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.
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.
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.