Nokea
The nurse is caring for a patient with possible cerebral edema who has a serum sodium level of 115 mmol/L, a decreasing level of consciousness (LOC), and has a headache. Which of the following prescribed interventions should the nurse implement first?
- A. Draw blood for arterial blood gases (ABGs).
- B. Administer 5% hypertonic saline intravenously.
- C. Administer acetaminophen 650 mg orally.
- D. Send patient for computed tomography (CT) of the head.
Correct Answer: B
Rationale: The patient's low sodium indicates that hyponatremia may be causing the cerebral edema, and the nurse's first action should be to correct the low sodium level. Acetaminophen will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may add some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.
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The nurse is caring for a patient with increased intracranial pressure (IICP). Which of the following are late signs of IICP? (Select all that apply.)
- A. Unilateral hemiparesis
- B. Papilledema
- C. Decorticate posturing
- D. Decerebrate posturing
- E. Hyperthermia
Correct Answer: C,D,E
Rationale: Late signs of IICP include decerebrate posturing, decorticate posturing, and hyperthermia. Unilateral hemiparesis and papilledema are early signs when the compensatory mechanism is intact.
The nurse is caring for a patient who is unconscious with a traumatic head injury and has a blood pressure of 72 mm Hg, and an intracranial pressure of 22 mm Hg. What is the cerebral perfusion pressure (CPP)?
- A. 50 mm Hg
- B. 94 mm Hg
- C. 72 mm Hg
- D. 22 mm Hg
Correct Answer: A
Rationale: The formula for cerebral perfusion pressure (CPP) is CPP = MAP - ICP, where MAP (mean arterial pressure) is calculated as (SBP + 2*DBP)/3. Given BP of 72 mm Hg (assuming this is the MAP as the question implies a single value), and ICP of 22 mm Hg, CPP = 72 - 22 = 50 mm Hg.
The nurse is caring for a patient admitted with bacterial meningitis who has a temperature of 38.9°C (102°F) and has prescriptions for all of the following collaborative interventions. Which action should the nurse take first?
- A. Administer ceftriaxone 1 g IV.
- B. Use a cooling blanket to lower temperature.
- C. Swab the nasopharyngeal mucosa for cultures.
- D. Give acetaminophen 650 mg PO.
Correct Answer: C
Rationale: Antibiotic therapy should be instituted rapidly in bacterial meningitis, but cultures must be done before antibiotics are started. As soon as the cultures are done, the antibiotic should be started. Hypothermia therapy and acetaminophen administration are appropriate but can be started after the other actions are implemented.
The nurse is admitting a patient who has a tumour of the right frontal lobe. Which of the following findings should the nurse expect to observe?
- A. Judgement changes
- B. Expressive aphasia
- C. Right-sided weakness
- D. Difficulty swallowing
Correct Answer: A
Rationale: The frontal lobes control intellectual activities such as judgement. Speech is controlled in the parietal lobe. Weakness and hemiplegia occur on the contralateral side from the tumour. Swallowing is controlled by the brain stem.
The nurse is admitting a patient to the emergency department (ED) who is unconscious following a head injury. The patient's partner and children are at the patient's side with many questions for the nurse regarding care. Which of the following actions is best for the nurse to take?
- A. Ask the family to stay in the waiting room until the initial assessment is completed.
- B. Allow the family to stay with the patient and briefly explain all procedures to them.
- C. Call the family's pastor or spiritual advisor to support them while initial care is given.
- D. Refer the family members to the hospital counselling service to deal with their anxiety.
Correct Answer: B
Rationale: The need for information about the diagnosis and care is very high in family members of acutely ill patients, and the nurse should allow the family to observe care and explain the procedures. A pastor or counselling service can offer some support, but research supports information as being more effective. Asking the family to stay in the waiting room will increase their anxiety.