Nokea
The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply.
- A. Contractures
- B. Hemorrhage
- C. Pressure ulcers
- D. Venous thromboembolism
- E. Pneumonia
Correct Answer: A,C,D,E
Rationale: Immobility in a vegetative state increases risks for contractures, pressure ulcers, DVT, and pneumonia. Hemorrhage is not a common complication of decreased LOC.
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The neurologic ICU nurse is admitting a patient following a craniotomy using the supratentorial approach. How should the nurse best position the patient?
- A. Position the patient supine.
- B. Maintain head of bed (HOB) elevated at 30 to 45 degrees.
- C. Position patient in prone position.
- D. Maintain bed in Trendelenberg position.
Correct Answer: B
Rationale: HOB elevation at 30-45 degrees reduces ICP in supratentorial craniotomy patients. Supine, prone, or Trendelenberg positions increase ICP risk.
Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patients current LOC?
- A. The patient occasionally makes incomprehensible sounds.
- B. The patients current LOC will likely become a permanent state.
- C. The patient may occasionally make nonpurposeful movements.
- D. The patient is incapable of spontaneous respirations.
Correct Answer: C
Rationale: Coma patients may exhibit nonpurposeful movements to stimuli. Verbal sounds are rare, comas are not permanent, and spontaneous respirations may persist.
The nurse is caring for a patient whose recent health history includes an altered LOC. What should be the nurses first action when assessing this patient?
- A. Assessing the patients verbal response
- B. Assessing the patients ability to follow complex commands
- C. Assessing the patients judgment
- D. Assessing the patients response to pain
Correct Answer: A
Rationale: Verbal response assessment, via orientation to time, person, and place, is the initial step in evaluating altered LOC. Other assessments follow based on findings.
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.
The nurse is providing care for a patient who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the patient has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
- A. The ability of the patient to follow instructions during the seizure.
- B. The success or failure of the care team to physically restrain the patient.
- C. The patients ability to explain his seizure during the postictal period.
- D. The patients activities immediately prior to the seizure.
Correct Answer: D
Rationale: Documenting pre-seizure activities helps identify triggers. Patients cannot follow instructions or explain seizures during or postictally, and restraint is contraindicated.