Exam 13: Nervous System Alterations

The nurse is to administer 100 mg phenytoin (Dilantin)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 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°.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 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?

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.)

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

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 physician orders,which order is of the highest priority?

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

The physician orders fosphenytoin (Cerebyx),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 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 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 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?

The nurse is caring for a patient admitted to the ED 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 nare.What is the most appropriate 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 physician order should the nurse institute first?

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

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