Sole Ch 14
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? a) Frequent neurological assessment b) Side to side position changes c) ROM to extremities d) Frequent oropharyngeal suctioning
A Nurses complete neurological assessments based on prescribed frequency and the severity of the patient's condition. The newly admitted patient has an altered neurological status, so frequent neurological assessments are most important to include in the patient's plan of care.
Which patient being cared for in the emergency department should the charge nurse evaluate first? a) A patient with a complete spinal cord injury at the C5 dermatome level b) A patient with a GCS score of 15 on a 3L nasal cannula c) An alert patient with a subdural bleed who is complaining of a headache d) An ischemic stroke patient with a blood pressure of 190/100 mmHg
A A patient with a C5 complete spinal injury is at risk for ineffective breathing patterns and should be assessed immediately for any airway compromise.
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? a) Implement droplet precautions upon admission b) Wash hands thoroughly before leaving the room c) Scrub the hub of all central line ports before use d) Dispose of all bloody dressings in biohazard bags
A Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection.
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? a) Ensure patency of IV line b) Mix drug with 0.9% normal saline c) Evaluate serum K+ level d) Obtain an IV infusion pump
A Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis).
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? a) Assist the patient to the floor and provide soft head support b) Insert a nasogastric tube and connect to continuous wall suction c) Open the patient's mouth and insert a padded tongue blade d) Restrain the patient's extremities until the seizure subsides
A To reduce the risk of further injury, a patient experiencing seizure activity while sitting in a chair should be assisted to the floor with head adequately supported.
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.) a) Make frequent neurological assessments b) Maintain CO2 level at 50 mmHg c) Maintain MAP less than 130 mmHg d) Prepare for thrombolytic administration e) Restrain affected limb to prevent injury
A, C The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure less than 120 mm Hg. In hemorrhagic stroke, the goal is a mean arterial pressure less than 130 mm Hg. Neurological assessments are compared with the baseline assessments performed in the ED. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. The CO2 should be maintained within normal limits; this value is elevated. The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy. Restraints should be avoided.
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.) a) Doll's eyes absent indicate a disruption in normal brainstem processing. b) Doll's eyes present indicate brainstem activity. c) Eye movement in the opposite direction as the head when turned indicates an intact reflex. d) Eye movement in the same direction as the head when turned indicates an intact reflex. e) Increased intracranial pressure (ICP) is a contraindication to the assessment of this reflex. f) Presence of cervical injuries is a contraindication to the assessment of this reflex.
A, B, C, E, F In unconscious patients with stable cervical spine, assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open. Note movement of eyes. The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.
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) Maintain body temperature b) Monitor BP c) Pad all bony prominences d) Use proper hand washing
B Maintaining perfusion to the spinal cord is critical in the management of spinal cord injury. Monitoring blood pressure is a priority.
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? a) Lasix 20mg IVP as needed b) 500 mL albumin IV infusion c) Decadron 10mg IVP d) Dilantin 50 mg IVP
B To ensure adequate cerebral perfusion, for a CVP of 2 mm Hg, blood pressure of 90/60 mmHg, and heart rate of 115 beats/min, an infusion of 500 mL of albumin is most appropriate.
A patient with a head injury has an intracranial pressure (ICP) of 18 mmHg. The blood pressure is 144/90 mm Hg, and mean arterial pressure (MAP) is 108 mmHg. What is the cerebral perfusion pressure (CPP)? a) 54 mmHg b) 72 mmHg c) 90 mmHg d) 126 mmhg
C CPP = MAP - ICP. In this case, CPP = 108 mm Hg - 18 mm Hg = 90 mm Hg. All other calculated responses are incorrect.
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? a) Administer over 2 minutes b) Administer w/ 0.9% normal saline c) Contact the provider d) Assess cardiac rhythm
C The ordered dose is an inappropriate maintenance dose. The nurse should contact the provider. Administering the dose over 2 minutes, administering with normal saline, and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.
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? a) The patient is exhibiting extension posturing b) The patient is exhibiting flexion posturing c) The patient is exhibiting purposeful movement d) The patient is withdrawing to stimulation
C This is a good example of purposeful movement that is sometimes seen in patients with reduced consciousness.
The nurse is preparing to monitor intracranial pressure (ICP) with a fluidfilled monitoring system. The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.) a) Use of a heparin flush solution b) Manually flushing the device "prn" c) Recording ICP as a "mean" value d) Use of a pressurized flush system e) Zero referencing the transducer system
C, E Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups. ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Monro. Manually flushing the device may result in an increase in ICP.
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? a) Assess for the presence of a headache b) Assess the patient's general orientation c) Determine the patient's drug allergies d) Determine the time of symptom onset
D Early intervention for ischemic stroke is recommended. Thrombolytics must be given within 3 hours of the onset of symptoms. Although assessment of allergies, as well accompanying symptoms such as a headache and general orientation, are a part of a complete neurological assessment and should be performed, time of onset of symptoms is critical to the type of treatment.
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? a) Have the patient blow the nose until clear b) Insert bilateral cotton nasal packing c) Place a nasal drip pad under the nose d) Suction the left nares until the drainage clears
C In the presence of suspected cerebrospinal fluid leak, drainage should be unobstructed and free flowing. Small bandages may be applied to allow for fluid collection and assessment.
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? a) Monitor the patient's airway patency b) Elevate the head of the patient's bed c) Increase supplemental oxygen delivery d) Support bony prominences with padding
A A GCS score of 3 is indicative of a deep coma. Given the assessed respiratory rate of 10 breaths/min combined with the GSC score of 3, the nurse must focus on maintaining the patient's airway.
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? a) Mannitol 1g IV b) Portable chest x-ray c) Seizure precautions d) Ancef 1g IV
A The patient's GCS score is 4 along with an ICP of 18 mm Hg. Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care, Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure.
The nurse admits a patient to the emergency department (ED) with a suspected cervical spine injury. What is the priority nursing action? a) Keep the neck in the hyperextended position b) Maintain proper head and neck alignment c) Prepare for immediate ET intubation d) Remove cervical collar upon arrival to the ED
B Alignment of the head and neck may help prevent spinal cord damage in the event of a cervical spine injury.
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? a) Administer acetaminophen as ordered for the headache b) Assess for a kinked urinary catheter and assess for bowel impaction c) Encourage the patient to take slow, deep breaths d) Notify the provider of the patient's blood pressure
B Autonomic dysreflexia, characterized by an exaggerated response of the sympathetic nervous system, can be triggered by a variety of stimuli, including a kinked indwelling catheter, which would result in bladder distension. Other causes that should be ruled out before pharmacological intervention include fecal impaction.
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? a) Administer over 2 minutes b) Administer over 20-30 minutes c) Mix medication with 0.9% normal saline d) Administer via central line
B In the presence of hypotension and bradycardia, administering the medication over 2 minutes is too fast. Phenytoin should be administered over 20 to 30 minutes.
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? a) Stop the infusion for 5 minutes b) Increase the dose by 2.5 mg/hr c) Notify the provider of the BP d) Begin weaning the infusion
B Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured. Following infusion, the patient's blood pressure remains dangerously high, so increasing the dose by 2.5 mg/hr is the best action by the nurse.
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? a) Contact the admitting physician b) Administer the drug over 10 minutes c) Mix medication with 0.9% normal saline d) Administer via central line
B The nurse can administer the medication over 10 minutes as prescribed (100 to 150 mg phenytoin equivalent [PE] over 1 full minute). The drug dose prescribed is appropriate for the patient's weight. Fosphenytoin does not have to be administered with normal saline or via a central line.
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 mmHg, 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? a) Obtain stat serum electrolytes b) Administer lorazepam c) Obtain stat portable chest x-ray d) Administer phenytoin
B The nurse should administer lorazepam as ordered; lorazepam is the first-line medication for the treatment of status epilepticus. Phenytoin is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes. Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.
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? a) Elevate the HOB 30 degrees b) Keep lights dim at all times c) Implement seizure precautions d) Maintain bed rest at all times
C Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF) in the subarachnoid space. As such, the patient can experience symptoms associated with cerebral irritation, such as photophobia and seizures. In addition, the patient is at increased risk for seizures because of a high temperature. The priority nursing action is to implement seizure precautions in an attempt to prevent injury.
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 mmHg, 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? a) Blood cultures (2 specimens) for temperature >101°F b) Acetaminophen (Tylenol) 650 mg per rectum c) 500 mL albumin infusion intravenously d) Decadron 20 mg IVP every 4 hours
C Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage. Once an aneurysm has been repaired surgically, blood pressure is allowed to rise to prevent vasospasm. Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion.
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? a) Altered cerebral spinal fluid production and reabsorption b) Decreased cerebral blood volume due to vessel constriction c) Increased cerebral blood volume due to vessel dilation d) No effect on cerebral blood flow (PaCO2 of 60 mm Hg is normal)
C Cerebral vessels dilate when PaCO2 levels increase, increasing cerebral blood volume.
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? a) pH 7.38; PaCO2 55 mm Hg; HCO3 22 mEq/L; PaO2 85 mm Hg b) pH 7.38; PaCO2 40 mm Hg; HCO3 24 mEq/L; PaO2 70 mm Hg c) pH 7.38; PaCO2 35 mm Hg; HCO3 24 mEq/L; PaO2 85 mm Hg d) pH 7.38; PaCO2 28 mm Hg; HCO3 26 mEq/L; PaO2 65 mm Hg
C Optimal gas exchange in a patient with increased intracranial pressure includes adequate oxygenation and ventilation of carbon dioxide. A pH of 7.38, PaCO2 of 35 mm Hg, and a PaO2 of 85 mm Hg indicates both. PaCO2 values greater than normal (35 to 45) can lead to cerebral vasodilatation and further increase cerebral blood volume and ICP. Carbon dioxide levels less than 35 mm Hg can lead to cerebral vessel vasoconstriction and ischemia. Adequate oxygenation of cerebral tissues is achieved by maintaining a PaO2 above 80 mm Hg.
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? a) Both pressures are high b) Both pressures are low c) ICP is high; CPP is normal d) ICP is high; CPP is low
C The ICP is above the normal level of 0 to 15 mm Hg. The CPP is within the normal range. All other listed responses are incorrect.
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? a) 2478 mg b) 5000 mg c) 10,794 mg d) 12,750 mg
C The dosing regimen is initiated with a bolus of 30 mg/kg over 15 minutes, followed in 45 minutes by a continuous intravenous infusion of 5.4 mg/kg/hr for 23 hours. (30 mg × 70 kg) + (5.4 mg × 70 kg) × 23 hours = 10,794 mg.
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)? a) Ensure adequate periods of rest between nursing interventions. b) Insert an oral airway and monitor respiratory rate and depth. c) Maintain neutral head alignment and avoid extreme hip flexion. d) Reduce ambient room temperature and administer antipyretics.
D In this scenario, the patient's temperature is elevated, which increases metabolic demands. Increases in metabolic demands increase cerebral blood flow and contribute to increased intracranial pressure (ICP). Cooling measures should be implemented. Insertion of an oral airway in an alert patient is contraindicated. While maintaining neutral head position and ensuring adequate periods of rest between nursing interventions are appropriate actions for patients with elevated ICP, treatment of the fever is of higher priority.
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? a) ICP of 10 mmHg b) CPP of 70 mmHg c) GCS score of 5 d) CVP of 2 mmHg
D Osmotic diuretics draw water from normal brain cells, decreasing ICP and increasing CPP and urine output. An ICP of 10 mm Hg and CPP of 70 mm Hg are within normal limits. A GCS score of 5, while not optimum, indicates a slight improvement. A CVP of 2 mmHg indicates hypovolemia. To ensure adequate cerebral perfusion, further action on the part of the nurse is necessary.
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? a) Insert bilateral ear plugs b) Monitor airway patency c) Maintain neutral head position d) Apply a small nasal drip pad
D Patient assessment findings are indicative of a skull fracture. The presence of strawcolored nasal draining may be indicative of a CSF leak. Drainage should be monitored and allowed to flow freely.
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? a) Hyperoxygenate during ET suctioning b) Elevate the patient's HOB 30 degrees c) Apply bilateral heel protectors after repositioning d) Provide rest periods between nursing interventions
D Sustained increases in ICP lasting longer than 5 minutes should be avoided. This is accomplished by spacing nursing care activities to allow for rest between activities.
After receiving the handoff report from the day shift charge nurse, which patient should the evening charge nurse assess first? a) A patient with meningitis complaining of photophobia b) A mechanically ventilated patient with a GCS of 6 c) A patient with bacterial meningitis on droplet precautions d) A patient with an intracranial pressure ICP of 20 mm Hg and an oral temperature of 104°F
D The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104°F as this is an abnormal finding and should be investigated further. A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress. Photophobia is an expected finding with meningitis, and droplet precautions are appropriate for a patient with bacterial meningitis.
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? a) Stimulate the patient hourly b) Continue to monitor the patient c) Elevate the head of the bed d) Notify the provider immediately
D These are classic symptoms of epidural hematomas: injury, lucid period, and progressive deterioration. The provider must be notified of this neurological emergency so that appropriate interventions can be implemented.
