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The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. Which position is most appropriate for the patient?
- A. Neck placed in a neutral position.
- B. Head raised slightly with hips flexed.
- C. Supine in gravity neutral position.
- D. Turn on right side with head elevated.
Correct Answer: A
Rationale: The patient is experiencing increased intracranial pressure. To assist with reducing the intracranial pressure, place the patient's neck in a neutral position (not flexed or extended) to promote venous drainage.
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Which is a sign of Cushing response?
- A. Increased pulse rate
- B. Increased blood pressure
- C. Widened pulse pressure
- D. Bradycardia
- E. Increased systolic blood pressure
- F. Uncontrolled thermoregulation
Correct Answer: C,D,E
Rationale: A widened pulse pressure, increased systolic blood pressure, and bradycardia are together called Cushing response. It is considered an important diagnostic sign of late-stage brain herniation.
The nurse is aware that the drug t-PA a tissue plasminogen activator, must be given within how many hours of the onset of symptoms to have maximum benefit?
- A. 3 hours
- B. 4 hours
- C. 6 hours
- D. 8 hours
Correct Answer: A
Rationale: t-PA must be given within 3 hours of the onset of symptoms to be beneficial.
A frantic family member is distressed about the flaccid paralysis of a relative following a spinal cord injury several hours ago. Which fact does the nurse know about this condition?
- A. It is an ominous indicator of permanent paralysis.
- B. It is possibly a temporary condition and will clear.
- C. It degenerates into a spastic paralysis.
- D. It will progress up the cord to cause seizures.
Correct Answer: B
Rationale: A period of flaccid paralysis following a cord injury is called areflexia, or spinal shock, and may be temporary.
For which reason is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
- A. The infection needs to be treated with IV antibiotics to prevent paralysis.
- B. The brain may swell quickly causing seizures.
- C. The disease can rapidly progress into respiratory failure.
- D. IV hydration is needed to prevent possible fatal hypotension.
Correct Answer: C
Rationale: Hospitalization is necessary for GBS patients because the disease progresses very quickly and respiratory failure may occur.
In which way will a nurse record the behavior when a patient with Alzheimer's disease attempts to eat using a napkin rather than a fork?
- A. Apraxia
- B. Agnosia
- C. Aphasia
- D. Dysphagia
Correct Answer: B
Rationale: Agnosia is a total or partial loss of the ability to recognize familiar objects or people through sensory stimuli as a result of organic brain damage.