Nokea
A patient is being admitted to the neurologic ICU following an acute head injury that has resulted in cerebral edema. When planning this patients care, the nurse would expect to administer what priority medication?
- A. Hydrochlorothiazide (HydroDIURIL)
- B. Furosemide (Lasix)
- C. Mannitol (Osmitrol)
- D. Spirolactone (Aldactone)
Correct Answer: C
Rationale: Mannitol, an osmotic diuretic, reduces cerebral edema by dehydrating brain tissue. Other diuretics like hydrochlorothiazide, furosemide, and spirolactone are not typically used for increased ICP.
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The nurse is caring for a patient who is in status epilepticus. What medication does the nurse know may be given to halt the seizure immediately?
- A. Intravenous phenobarbital (Luminal)
- B. Intravenous diazepam (Valium)
- C. Oral lorazepam (Ativan)
- D. Oral phenytoin (Dilantin)
Correct Answer: B
Rationale: IV diazepam is used to stop status epilepticus immediately. Phenobarbital and phenytoin are for maintenance, and oral medications are inappropriate during active seizures.
The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate action?
- A. Position the patient in the high Fowlers position as tolerated.
- B. Administer osmotic diuretics as ordered.
- C. Participate in interventions to increase cerebral perfusion pressure.
- D. Prepare the patient for craniotomy.
Correct Answer: C
Rationale: The CPP (MAP - ICP = 55 mm Hg) is low; normal is 70-100 mm Hg. Interventions to increase CPP are needed to prevent neurologic damage. High Fowlers, diuretics, or craniotomy may worsen the condition.
The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response?
- A. Inform the care team and assess for further signs of possible increased ICP.
- B. Administer bronchodilators as ordered and monitor the patients LOC.
- C. Increase the patients bed height and reassess in 30 minutes.
- D. Administer a bolus of normal saline as ordered.
Correct Answer: A
Rationale: Increased respiratory effort may indicate rising ICP, requiring immediate team notification and further assessment. Bronchodilators, bed elevation, or saline are inappropriate initial actions.
When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH?
- A. Fluid restriction
- B. Transfusion of platelets
- C. Transfusion of fresh frozen plasma (FFP)
- D. Electrolyte restriction
Correct Answer: A
Rationale: SIADH causes fluid overload, requiring fluid restriction and electrolyte monitoring. Platelet or plasma transfusions and electrolyte restriction are not indicated.
A clinic nurse is caring for a patient diagnosed with migraine headaches. During the patient teaching session, the patient questions the nurse regarding alcohol consumption. What would the nurse be correct in telling the patient about the effects of alcohol?
- A. Alcohol causes hormone fluctuations.
- B. Alcohol causes vasodilation of the blood vessels.
- C. Alcohol has an excitatory effect on the CNS.
- D. Alcohol diminishes endorphins in the brain.
Correct Answer: B
Rationale: Alcohol's vasodilatory effect can worsen migraines. It depresses the CNS, does not affect hormones significantly, and does not reduce endorphins in this context.