Exam 14: Nervous System Alterations

The nurse is caring for a patient who has a diminished level of consciousness and who is mechanically ventilated.While performing endotracheal suctioning,the patient reaches up in an attempt to grab the suction catheter.What is the best interpretation by the nurse?

The nurse admits a patient to the critical care unit following a motorcycle crash.Assessment findings by the nurse include blood pressure 100/50 mm Hg,heart rate 58 beats/min,respiratory rate 30 breaths/min,and temperature of 100.5°F.The patient is lethargic,responds to voice but falls asleep readily when not stimulated.Which nursing action is most important to include in this patient's plan of care?

The nurse is to administer 100 mg phenytoin intravenous (IV).Vital signs assessed by the nurse include blood pressure 90/60 mm Hg,heart rate 52 beats/min,respiratory rate 18 breaths/min,and oxygen saturation (SpO₂)99% on supplemental oxygen at 3 L/min by cannula.To prevent complications,what is the best action by the nurse?

Which patient being cared for in the emergency department should the charge nurse evaluate first?

The nurse is preparing to monitor intracranial pressure (ICP)with a fluid-filled monitoring system.The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.)

The nurse is preparing to administer a routine dose of phenytoin.The provider orders phenytoin 500 mg intravenous every 6 hours.What is the best action by the nurse?

In an unconscious patient,eye movements are tested by the oculocephalic reflex.Which statements regarding the testing of this reflex are true? (Select all that apply.)

The provider prescribes fosphenytoin,1.5 g intravenous (IV)loading dose,for a 75-kg patient in status epilepticus.What is the most important action by the nurse?

The nurse is caring for a patient 3 days following a complete cervical spine injury at the C3 level.The patient is in spinal shock.Following emergent intubation and mechanical ventilation,what is the priority nursing action?

A patient with a head injury has an intracranial pressure (ICP)of 18 mm Hg.The blood pressure is 144/90 mm Hg,and mean arterial pressure (MAP)is 108 mm Hg.What is the cerebral perfusion pressure (CPP)?

While caring for a patient with a traumatic brain injury,the nurse assesses an ICP of 20 mm Hg and a CPP of 85 mm Hg.What is the best interpretation by the nurse?

The nurse is caring for a patient who was hit on the head with a hammer.The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department with a GCS score of 15.One hour later,the nurse assesses a GCS score of 3.What is the priority nursing action?

The nurse is caring for a patient admitted with new onset of slurred speech,facial droop,and left-sided weakness 8 hours ago.Diagnostic computed tomography scan rules out the presence of an intracranial bleed.Which actions are most important to include in the patient's plan of care? (Select all that apply.)

The nurse is caring for a patient admitted to the emergency department following a fall from a 10-foot ladder.Upon admission,the nurse assesses the patient to be awake,alert,and moving all four extremities.The nurse also notes bruising behind the left ear and straw-colored drainage from the left naris.What is the most appropriate nursing action?

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage.The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure of 95/50 mm Hg,heart rate 110 beats/min,respiratory rate 20 breaths/min,oxygen saturation (SpO₂)95% on 3 L/min oxygen via nasal cannula,and a temperature of 101.5°F.Which provider prescription should the nurse institute first?

The nurse is caring for a mechanically ventilated patient with a brain injury.Arterial blood gas values indicate a PaCO₂ of 60 mm Hg.The nurse understands this value to have which effect on cerebral blood flow?

The nurse assesses a patient with a skull fracture to have a Glasgow Coma Scale score of 3.Additional vital signs assessed by the nurse include blood pressure 100/70 mm Hg,heart rate 55 beats/min,respiratory rate 10 breaths/min,oxygen saturation (SpO₂)94% on oxygen at 3 L per nasal cannula.What is the priority nursing action?

The nurse is caring for a patient admitted to the emergency department in status epilepticus.Vital signs assessed by the nurse include blood pressure 160/100 mm Hg,heart rate 145 beats/min,respiratory rate 36 breaths/min,oxygen saturation (SpO₂)96% on 100% supplemental oxygen by non-rebreather mask.After establishing an intravenous (IV)line,which prescription by the provider should the nurse implement first?

The nurse responds to a high heart rate alarm for a patient in the neurological intensive care unit.The nurse arrives to find the patient sitting in a chair experiencing a tonic-clonic seizure.What is the best nursing action?

The nurse is caring for a patient admitted with bacterial meningitis.Vital signs Assessed by the nurse include blood pressure 110/70 mm Hg,heart rate 110 beats/min,respiratory rate 30 breaths/min,oxygen saturation (SpO₂)95% on supplemental oxygen at 3 L/min,and a temperature 103.5°F.What is the priority nursing action?