Exam 14: Nervous System Alterations

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

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?

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 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?

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?

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 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?

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?

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 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 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 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 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?

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?

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?

In an unconscious patient,eye movements are tested by the oculocephalic reflex.Which statements regarding the testing of this reflex are true?

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 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?

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 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?