Exam 14: Nervous System Alterations

The nurse is caring for a patient with an ICP of 18 mm Hg and a GCS score of 3.Following the administration of mannitol (Osmitrol),which assessment finding by the nurse requires further action?

The nurse is preparing to administer 100 mg of phenytoin to a patient in status epilepticus.To prevent patient complications,what is the best action by the nurse?

The nurse is caring for a patient from a rehabilitation center with a preexisting complete cervical spine injury who is complaining of a severe headache.The nurse assesses a blood pressure of 180/90 mm Hg,heart rate 60 beats/min,respirations 24 breaths/min,and 50 mL of urine via indwelling urinary catheter for the past 4 hours.What is the best action by the nurse?

While caring for a patient with a closed head injury,the nurse assesses the patient to be alert with a blood pressure 130/90 mm Hg,heart rate 60 beats/min,respirations 18 breaths/min,and a temperature of 102°F.To reduce the risk of increased intracranial pressure (ICP)in this patient,what is (are)the priority nursing action(s)?

After receiving the handoff report from the day shift charge nurse,which patient should the evening charge nurse assess first?

The nurse receives a patient from the emergency department following a closed head injury.After insertion of an ventriculostomy,the nurse assesses the following vital signs: blood pressure 100/60 mm Hg,heart rate 52 beats/min,respiratory rate 24 breaths/min,oxygen saturation (SpO₂)97% on supplemental oxygen at 45% via Venturi mask,Glasgow Coma Scale score of 4,and intracranial pressure (ICP)of 18 mm Hg.Which provider prescription should the nurse institute first?

The nurse admits a patient to the emergency department with new onset of slurred speech and right-sided weakness.What is the priority nursing action?

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis.To prevent the spread of nosocomial infections to other patients,what is the best action by the nurse?

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm.Assessment by the nurse notes blood pressure 90/60 mm Hg,heart rate 115 beats/min,respiratory rate 28 breaths/min,oxygen saturation (SpO₂)99% on supplemental oxygen at 3L/min by cannula,a Glasgow Coma Score of 4,and a central venous pressure (CVP)of 2 mm Hg.After reviewing the provider prescriptions,which order is of the highest priority?

The nurse,caring for a patient following a subarachnoid hemorrhage,begins a nicardipine infusion.Baseline blood pressure assessed by the nurse is 170/100 mm Hg.Five minutes after beginning the infusion at 5 mg/hr,the nurse assesses the patient's blood pressure to be 160/90 mm Hg.What is the best action by the nurse?

While caring for a patient with a basilar skull fracture,the nurse assesses clear drainage from the patient's left naris.What is the best nursing action?

The nurse is caring for a mechanically ventilated patient with a sustained ICP of 18 mm Hg.The nurse needs to perform an hourly neurological assessment,suction the endotracheal tube,perform oral hygiene care,and reposition the patient to the left side.What is the best action by the nurse?

The nurse admits a patient to the emergency department ( ED )with a suspected cervical spine injury.What is the priority nursing action?

The provider has opted to treat a patient with a complete spinal cord injury with Solumedrol.The provider orders 30 mg/kg over 15 minutes followed in 45 minutes with an infusion of 5.4 mg/kg/hr for 23 hours.What is the total 24-hour dose for the 70-kg patient?

The nurse is caring for a mechanically ventilated patient admitted with a traumatic brain injury.Which arterial blood gas value assessed by the nurse indicates optimal gas exchange for a patient with this type of injury?