Chapter 9 - Prioritization, Delegation, and Assignment
The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response? •"Your wife was not admitted within the time frame that alteplase is usually given." •"This drug is used primarily for clients who experience an acute heart attack." •"Alteplase dissolves clots and may cause more bleeding into your wife's brain." •"Your wife had gallbladder surgery just 6 months ago, so we can't use alteplase."
•"Alteplase dissolves clots and may cause more bleeding into your wife's brain." •Alteplase is a clot buster. In a client who has experienced hemorrhagic stroke, there is already bleeding into the brain. A drug, such as alteplase, dissolves the clot and can cause more bleeding in the brain. The other statements about the use of alteplase are accurate but are not pertinent to this client's diagnosis.
The nurse is preparing to discharge a client with chronic low back pain. Which statement by the client indicates the need for additional teaching? •"I will avoid exercise because the pain gets worse." •"I will use heat or ice to help control the pain." •"I will not wear high-heeled shoes at home or work." •"I will purchase a firm mattress to replace my old one."
•"I will avoid exercise because the pain gets worse." •Exercises are used to strengthen the back, relieve pressure on compressed nerves, and protect the back from reinjury. Ice, heat, and firm mattresses are appropriate interventions for back pain. People with chronic back pain should avoid wearing high-heeled shoes at all times.
A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene? •"You should avoid consumption of all forms of alcohol." •"Wear your medical alert bracelet at all times." •"Protect your loved one's airway during a seizure." •"It's OK to take over-the-counter medications."
•"It's OK to take over-the-counter medications." •A client with a seizure disorder should not take over-the-counter medications without consulting with the health care provider first. The other three statements are appropriate teaching points for clients with seizure disorders and their families.
Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit? •A 26-year-old client with a basilar skull fracture who has clear drainage coming out of the nose •A 42-year-old client admitted several hours ago with a headache and a diagnosis of a ruptured berry aneurysm •A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due •A 65-year-old client with an astrocytoma who has just returned to the unit after undergoing craniotomy
•A 46-year-old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due •Of the clients listed, the client with bacterial meningitis is in the most stable condition and likely the least complex. An RN from the medical unit would be familiar with administering IV antibiotics. The other clients require assessments and care from RNs more experienced in caring for clients with neurologic diagnoses.
For which client with severe migraine headaches would the nurse question an order for sumatriptan? •A 58-year-old client with gastrointestinal reflux disease •A 48-year-old client with hypertension •A 65-year-old client with mild emphysema •A 72-year-old client with hyperthyroidism
•A 48-year-old client with hypertension •Sumatriptan is a triptan preparation developed to treat migraine headaches. Most are contraindicated in clients with actual or suspected ischemic heart disease, cerebrovascular ischemia, hypertension, and peripheral vascular disease and in those with Prinzmetal angina because of the potential for coronary vasospasm.
After the nurse receives the change-of-shift report at 7:00 am, which client must the nurse assess *first*? •A 23-year-old client with a migraine headache who reports severe nausea associated with retching •A 45-year-old client who is scheduled for a craniotomy in 30 minutes and needs preoperative teaching •A 59-year-old client with Parkinson disease who will need a swallowing assessment before breakfast •A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain
•A 63-year-old client with multiple sclerosis (MS) who has an oral temperature of 101.8°F (38.8°C) and flank pain •Urinary tract infections (UTIs) are a frequent complication in clients with MS because of the effect of the disease on bladder function, and UTIs may lead to sepsis in these clients. The elevated temperature and flank pain suggest that this client may have pyelonephritis. The health care provider should be notified immediately so that IV antibiotic therapy can be started quickly. The other clients should be assessed as soon as possible, but their needs are not as urgent as those of this client.
Which client should the charge nurse assign to a new graduate RN who is orientating to the neurologic unit? •A 28-year-old newly admitted client with a spinal cord injury •A 67-year-old client who had a stroke 3 days ago and has left-sided weakness •An 85-year-old client with dementia who is to be transferred to long-term care today •A 54-year-old client with Parkinson disease who needs assistance with bathing
•A 67-year-old client who had a stroke 3 days ago and has left-sided weakness •The new graduate RN who is on orientation to the unit should be assigned to care for clients with stable, noncomplex conditions, such as the client with stroke. The task of helping the client with Parkinson disease to bathe is best delegated to the unlicensed assistive personnel (UAP). The client being transferred to the nursing home, and the newly admitted client with spinal cord injury should be assigned to experienced nurses.
Which client should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? •A 34-year-old client with newly diagnosed multiple sclerosis (MS) •A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS) •A 56-year-old client with Guillain-Barré syndrome (GBS) in respiratory distress •A 25-year-old client admitted with a C4-level spinal cord injury (SCI)
•A 68-year-old client with chronic amyotrophic lateral sclerosis (ALS) •The traveling nurse is relatively new to neurologic nursing and should be assigned clients whose condition is stable and not complex, such as the client with chronic ALS. The newly-diagnosed client with MS will need a lot of teaching and support. The client with respiratory distress will need frequent assessments and may need to be transferred to the intensive care unit. The client with a C4-level SCI is at risk for respiratory arrest. All three of these clients should be assigned to nurses experienced in neurologic nursing care.
Which actions should the nurse delegate to an experienced unlicensed assistive personnel (UAP) when caring for a client with a thrombotic stroke who has residual left-sided weakness? *Select all that apply.* •Assisting the client to reposition every 2 hours •Reapplying pneumatic compression boots •Reminding the client to perform active range-of-motion (ROM) exercises •Assessing the extremities for redness and edema •Setting up meal trays and assisting with feeding •Using a lift to assist the client up to a bedside chair
•Assisting the client to reposition every 2 hours •Reapplying pneumatic compression boots •Reminding the client to perform active range-of-motion (ROM) exercises •Setting up meal trays and assisting with feeding •Using a lift to assist the client up to a bedside chair •An experienced UAP would know how to reposition the client, reapply compression boots, and feed a client, and would remind the client to perform activities the client has been taught to perform. UAPs are also trained to use a client lift to get clients into or out of bed. Assessing for redness and swelling (signs of deep vein thrombosis) requires additional education and skill, appropriate to the professional nurse.
A client who has Alzheimer disease is hospitalized with new-onset angina. Her spouse tells the nurse that he does not sleep well because he needs to be sure the client does not wander during the night. He insists on checking each of the medications the nurse gives the client to be sure they are "the same pills she takes at home." Based on this information, which nursing problem is *most* appropriate for this client? •Acute client confusion •Care provider role stress •Increased risk for falls •Noncompliance with therapeutic plan
•Care provider role stress •The husband's statement about lack of sleep and concern about whether his wife is receiving the correct medications are behaviors that support the problem of care provider role stress. The husband's statements about how he monitors the client and his concern with medication administration do not indicate difficulty complying with the therapeutic plan. The client may be confused, but the nurse would need to gather more data, and this is not the main focus of the husband's concerns. Falls are not an immediate concern at this time.
A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take *first*? •Administer the ordered acetaminophen •Check the Foley tubing for kinks or obstruction •Adjust the temperature in the client's room •Notify the health care provider about the change in status
•Check the Foley tubing for kinks or obstruction •The client's signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the health care provider may be necessary if nursing actions do not resolve symptoms.
The nurse is floated from the emergency department to the neurologic floor. Which action should the nurse delegate to the unlicensed assistive personnel (UAP) when providing nursing care for a client with a spinal cord injury? •Assessing the client's respiratory status every 4 hours •Checking and recording the client's vital signs every 4 hours •Monitoring the client's nutritional status, including calorie counts •Instructing the client how to turn, cough, and breathe deeply every 2 hours
•Checking and recording the client's vital signs every 4 hours •The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses.
The nurse is in charge of developing a standard plan of care for an Alzheimer disease care facility and is responsible for assigning and supervising resident care given by LPNs/LVNs and delegating and supervising care given by unlicensed assistive personnel (UAP). Which activity is *best* to assign to the LPN/LVN team leaders? •Checking for improvement in resident memory after medication therapy is initiated •Using the Mini-Mental State Examination to assess residents every 6 months •Assisting residents in using the toilet every 2 hours to decrease risk for urinary incontinence •Developing individualized activity plans after consulting with residents and family
•Checking for improvement in resident memory after medication therapy is initiated •LPN/LVN education and team leader responsibilities include checking for the therapeutic and adverse effects of medications. Changes in the residents' memory would be communicated to the RN supervisor, who is responsible for overseeing the plan of care for each resident. Assessing for changes in score on the Mini-Mental State Examination and developing the plan of care are RN responsibilities. Assisting residents with personal care and hygiene would be delegated to UAPs working at the long-term care facility.
All of the following nursing care activities are included in the care plan for a 78-year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the unlicensed assistive personnel (UAP)? *Select all that apply.* •Checking for orthostatic changes in pulse and blood pressure •Assessing for improvement in tremor after levodopa is given •Reminding the client to allow adequate time for meals •Monitoring for signs of toxic reactions to anti-Parkinson medications •Assisting the client with prescribed strengthening exercises •Adapting the client's preferred activities to his level of function
•Checking for orthostatic changes in pulse and blood pressure •Reminding the client to allow adequate time for meals •Assisting the client with prescribed strengthening exercises •UAP education and scope of practice include checking pulse and blood pressure measurements. The nurse would be sure to instruct the UAP to report heart rate and blood pressure findings. In addition, UAPs can reinforce previous teaching or skills taught by the RN or personnel in other disciplines, such as speech or physical therapists. Evaluating client response to medications and developing and individualizing the plan of care require RN-level education and scope of practice.
A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN/LVN? *Select all that apply.* •Checking the client's skin for pressure from the device •Assessing the client's neurologic status for changes •Observing the halo insertion sites for signs of infection •Cleaning the halo insertion sites with hydrogen peroxide •Developing the nursing plan of care for the client •Administering oral medications as ordered
•Checking the client's skin for pressure from the device •Observing the halo insertion sites for signs of infection •Cleaning the halo insertion sites with hydrogen peroxide •Administering oral medications as ordered •Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Administering oral drugs is within the scope of practice for an LPN/LVN. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN.
After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? •Documenting the seizure •Performing neurologic checks •Checking the client's vital signs •Restraining the client for protection
•Checking the client's vital signs •Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary to prevent injury.
The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's *best* action? •Perform a complete neurologic assessment •Assess the cranial nerve functions •Contact the Rapid Response Team •Reassess the client in 30 minutes
•Contact the Rapid Response Team •A change in level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined. If a decline occurs, contact the Rapid Response Team or health care provider immediately. The nurse should also perform a focused assessment to determine if there are any other changes.
The nurse is preparing a nursing care plan for a client with a spinal cord injury (SCI) for whom problems of decreased mobility and inability to perform activities of daily living (ADLs) have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes *priority*? •Risk for injury •Decreased nutrition •Difficulty with coping •Impairment of body image
•Difficulty with coping •The client's statement indicates difficulty with coping in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing problems may be appropriate for a client with SCI but are not related to the client's statement.
The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student requires that the nurse intervene *most* rapidly? •Entering the room without putting on a protective mask and gown •Instructing the family that visits are restricted to 10 minutes •Giving the client a warm blanket when he says he feels cold •Checking the client's pupil response to light every 30 minutes
•Entering the room without putting on a protective mask and gown •Meningococcal meningitis is spread through contact with respiratory secretions, so use of a mask and gown is required to prevent transmission of the infection to staff members or other clients. The other actions may or may not be appropriate. The presence of a family member at the bedside may decrease client confusion and agitation. Clients with hyperthermia frequently report feeling chilled, but warming the client is not an appropriate intervention. Checking the pupils' response to light is appropriate but is not needed every 30 minutes and is uncomfortable for a client with photophobia.
A client with multiple sclerosis tells the unlicensed assistive personnel (UAP) after physical therapy that she is too tired to take a bath. What is the *priority* nursing concern at this time? •Fatigue •Inability to perform activities of daily living (ADLs) •Decreased mobility •Muscular weakness
•Fatigue •At this time, based on the client's statement, the priority is inability to perform ADLs most likely related to being tired (fatigue) after physical therapy. The other three nursing concerns are appropriate to a client with MS but are not related to the client's statement.
The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? *Select all that apply.* •Foods that contain tyramine, such as alcohol and aged cheese, should be avoided •Drugs such as nitroglycerin and nifedipine should be avoided •Abortive therapy is aimed at eliminating the pain during the aura •A potential side effect of medications is rebound headache •Complementary therapies such as biofeedback and relaxation may be helpful •Estrogen therapy should be continued as prescribed by the client's health care provider
•Foods that contain tyramine, such as alcohol and aged cheese, should be avoided •Drugs such as nitroglycerin and nifedipine should be avoided •Abortive therapy is aimed at eliminating the pain during the aura •A potential side effect of medications is rebound headache •Complementary therapies such as biofeedback and relaxation may be helpful •Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate and should be included in the teaching plan.
The nurse has just admitted a client with bacterial meningitis who reports a severe headache with photophobia and has a temperature of 102.6°F (39.2°C) orally. Which prescribed intervention should be implemented *first*? •Administer codeine 15 mg orally for the client's headache •Infuse ceftriaxone 2000 mg IV to treat the infection •Give acetaminophen 650 mg orally to reduce the fever •Give furosemide 40 mg IV to decrease intracranial pressure
•Infuse ceftriaxone 2000 mg IV to treat the infection •Bacterial meningitis is a medical emergency, and antibiotics are administered even before the diagnosis is confirmed (after specimens have been collected for culture). The other interventions will also help to reduce central nervous system stimulation and irritation and should be implemented as soon as possible but are not as important as starting antibiotic therapy.
The RN is supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene? •Instructing the client to sit up straight and the client responds with a puzzled expression •Moving the client's food tray to the right side of his over-bed table •Assisting the client with passive range-of-motion (ROM) exercises •Combing the hair on the left side of the client's head when the client always combs his hair on the right side
•Instructing the client to sit up straight and the client responds with a puzzled expression •Clients with right cerebral hemisphere stroke often manifest neglect syndrome. They lean to the left and, when asked, respond that they believe they are sitting up straight. They often neglect the left side of their bodies and ignore food on the left side of their food trays. The nurse needs to remind the student of this phenomenon and discuss the appropriate interventions.
A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the *priority* nursing assessment? •Determine the level at which the client has intact sensation •Assess the level at which the client has retained mobility •Check blood pressure and pulse for signs of spinal shock •Monitor respiratory effort and oxygen saturation level
•Monitor respiratory effort and oxygen saturation level •The first priority for the client with a spinal cord injury is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority.
The RN notes that a client with myasthenia gravis has an elevated temperature (102.2°F [39°C]), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and is incontinent of urine and stool. What is the nurse's best action at this time? •Administer an acetaminophen suppository •Notify the health care provider immediately •Recheck vital signs in 1 hour •Reschedule the client's physical therapy
•Notify the health care provider immediately •The changes that the RN notes are characteristic of myasthenic crisis, which often follows some type of infection. The client is at risk for inadequate respiratory function. In addition to notifying the health care provider or Rapid Response Team, the nurse should carefully monitor the client's respiratory status. The client may need intubation and mechanical ventilation.
A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be *best* to assign to an LPN/LVN whom the nurse is supervising? *Select all that apply.* •Observing and documenting the onset and duration of any seizure activity •Administering phenytoin 200 mg PO three times a day •Teaching the client about the need for frequent tooth brushing and flossing •Developing a discharge plan that includes referral to the Epilepsy Foundation •Assessing for adverse effects caused by new antiseizure medications •Turning the client to his or her side to avoid aspiration
•Observing and documenting the onset and duration of any seizure activity •Administering phenytoin 200 mg PO three times a day •Turning the client to his or her side to avoid aspiration •Any nursing staff member who is involved in caring for the client should observe for the onset and duration of seizures (although a more detailed assessment of seizure activity should be done by the RN). Administration of medications is included in LPN/LVN education and scope of practice. Turning the client on his or her side to avoid aspiration is certainly within the scope of practice for an LPN/LVN. Teaching, discharge planning, and assessment for adverse effects of new medications are complex activities that require RN-level education and scope of practice.
What is the *priority* nursing concern for a client experiencing a migraine headache? •Pain •Anxiety •Hopelessness •Risk for brain injury
•Pain •The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other problems are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating.
A client with Parkinson disease has a problem with decreased mobility related to neuromuscular impairment. The nurse observes the unlicensed assistive personnel (UAP) performing all of these actions. For which action must the nurse intervene? •Helping the client ambulate to the bathroom and back to bed •Reminding the client not to look at his feet when he is walking •Performing the client's complete bathing and oral care •Setting up the client's tray and encouraging the client to feed himself
•Performing the client's complete bathing and oral care •Although all of these actions fall within the scope of practice for a UAP, the UAP should help the client with morning care as needed, but the goal is to keep this client as independent and mobile as possible. The client should be encouraged to perform as much morning care as possible. Assisting the client in ambulating, reminding the client not to look at his feet (to prevent falls), and encouraging the client to feed himself are all appropriate to the goal of maintaining independence.
A client who had a stroke needs to be fed. What instruction should the nurse give to the unlicensed assistive personnel (UAP) who will feed the client? •Position the client sitting up in bed before he or she is fed •Check the client's gag and swallowing reflexes •Feed the client quickly because there are three more clients to feed •Suction the client's secretions between bites of food
•Position the client sitting up in bed before he or she is fed •Positioning the client in a sitting position decreases the risk of aspiration. The UAP is not trained to assess gag or swallowing reflexes. The client should not be rushed during feeding. A client who needs suctioning performed between bites of food is not handling secretions and is at risk for aspiration. Such a client should be assessed further before feeding.
The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? •Completing the admission assessment •Setting up oxygen and suction equipment •Placing a padded tongue blade at the bedside •Padding the side rails before the client arrives
•Setting up oxygen and suction equipment •The LPN/LVN scope of practice includes setting up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Controversy exists as to whether padded side rails actually provide safety, and their use may embarrass the client and family. Tongue blades should not be at the bedside and should never be inserted into the client's mouth after a seizure begins.
An LPN/LVN, under the RN's supervision, is assigned to provide nursing care for a client with Guillain-Barré syndrome (GBS). What observation should the LPN/LVN be instructed to report *immediately*? •Reports of numbness and tingling •Facial weakness and difficulty speaking •Rapid heart rate of 102 beats/min •Shallow respirations and decreased breath sounds
•Shallow respirations and decreased breath sounds •The priority intervention for a client with GBS is maintaining adequate respiratory function. Clients with GBS are at risk for respiratory failure, which requires urgent intervention. The other findings are important and should be reported to the nurse, but they are not life threatening.
The nurse is providing care for a client newly diagnosed with early Alzheimer disease (AD). On assessment, which finding would the nurse expect to discover? •Short-term memory impairment •Rapid mood swings •Physical aggressiveness •Increased confusion at night
•Short-term memory impairment •One of the first symptoms of AD is short-term memory impairment. Behavioral changes that occur late in the disease progression include rapid mood swings, tendency toward physical and verbal aggressiveness, and increased confusion at night (when light is inadequate) or when the client is excessively fatigued.
The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? *Select all that apply.* •Stroking the client's inner thigh •Pulling on the client's pubic hair •Initiating intermittent straight catheterization •Pouring warm water over the client's perineum •Tapping the bladder to stimulate the detrusor muscle •Reminding the client to void in a urinal every hour while awake
•Stroking the client's inner thigh •Pulling on the client's pubic hair •Pouring warm water over the client's perineum •Tapping the bladder to stimulate the detrusor muscle •All of the strategies except straight catheterization may stimulate voiding in clients with a spinal cord injury (SCI). Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding. To use a urinal, the client must have bladder control, which is often absent after SCI. In addition, every hour while awake would be too often and ignore the bladder filling at night.
The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IV push every 6 hours to relieve symptoms of right arm weakness and headache. Which assessment information concerns the nurse the *most*? •The client no longer recognizes family members •The blood glucose level is 234 mg/dL (13 mmol/L) •The client reports a continuing headache •The daily weight has increased 2.2 lb (1 kg)
•The client no longer recognizes family members •The inability to recognize family members is a new neurologic deficit for this client and indicates a possible increase in intracranial pressure (ICP). This change should be communicated to the health care provider immediately so that treatment can be initiated. The continuing headache also indicates that the ICP may be elevated but is not a new problem. The glucose elevation and weight gain are common adverse effects of dexamethasone that may require treatment but are not emergencies.
The critical care nurse is assessing a client whose baseline Glasgow Coma Scale (GCS) score in the emergency department was 5. The current GCS score is 3. What is the nurse's *best* interpretation of this finding? •The client's condition is improving •The client's condition is deteriorating •The client will need intubation and mechanical ventilation •The client's medication regime will need adjustments
•The client's condition is deteriorating •The GCS is used in many acute care settings to establish baseline data in these areas: eye opening, motor response, and verbal response. The client is assigned a numeric score for each of these areas. The lower the score, the lower the client's neurologic function. A decrease of 2 or more points in the Glasgow Coma Scale score total is clinically significant and should be communicated to the health care provider immediately.
A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of *greatest* concern? •The gums appear enlarged and inflamed •The white blood cell count is 2300/mm3 (2.3 x 109/L) •The client sometimes forgets to take the phenytoin until the afternoon •The client wants to renew her driver's license in the next month
•The white blood cell count is 2300/mm3 (2.3 x 109/L) •Leukopenia is a serious adverse effect of phenytoin therapy and would require discontinuation of the medication. The other data indicate a need for further assessment or client teaching but will not require a change in medical treatment for the seizures.
A 70-year-old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." Which collaborative interventions will the nurse implement *first*? •Place the client on the hospital alcohol withdrawal protocol •Transport the client to the radiology department for a computed tomography (CT) scan •Make a referral to the social services department •Give the client phenytoin 100 mg PO
•Transport the client to the radiology department for a computed tomography (CT) scan •The client's history and assessment data indicate that he may have a chronic subdural hematoma. The priority goal is to obtain a rapid diagnosis and send the client to surgery to have the hematoma evacuated. The other interventions also should be implemented as soon as possible, but the initial nursing activities should be directed toward diagnosis and treatment of any intracranial lesion.
Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure? •Turn the client to one side •Give lorazepam 2 mg IV •Administer oxygen via nonrebreather mask •Assess the client's level of consciousness
•Turn the client to one side •The priority action during a generalized tonic-clonic seizure is to protect the airway by turning the client to one side to prevent aspiration. Administering lorazepam should be the next action because it will act rapidly to control the seizure. Although oxygen may be useful during the postictal phase, the hypoxemia during tonic-clonic seizures is caused by apnea, which cannot be corrected by oxygen administration. Checking level of consciousness is not appropriate during the seizure because generalized tonic-clonic seizures are associated with a loss of consciousness.
A client with Guillain-Barré syndrome (GBS) is to undergo plasmapheresis to remove circulating antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced unlicensed assistive personnel (UAP)? •Observe the access site for ecchymosis or bleeding •Instruct the client that there will be three or four treatments •Weigh the client before and after the procedure •Assess the access site for bruit and thrill every 2 to 4 hours
•Weigh the client before and after the procedure •The scope of practice for an experienced UAP would include weighing clients. Observing, assessing, and providing instructions all require additional educational preparation and are appropriate to the scope of practice for a professional nurse.
The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? *Select all that apply.* •When did you first experience the headache symptoms? •Who is the Mayor of Cleveland? •What is your health care provider's name? •What year and month is this? •What is your parents' address? •What is the name of this health care facility?
•When did you first experience the headache symptoms? •What is your health care provider's name? •What year and month is this? •What is the name of this health care facility? •After determining alertness in a client, the next step is to evaluate orientation. When the client's attention is engaged, ask him or her questions to determine orientation. Varying the sequence of questioning on repeated assessments prevents the client from memorizing the answers. Responses that indicate orientation include the ability to answer questions about person, place, and time by asking for information such as the client's ability to relate the onset of symptoms, the name of his or her health care provider or nurse, the year and month, his or her address, and the name of the referring physician or health care agency. Asking about mayors' names or parents' address may be inappropriate to assess orientation.
