Nervous system Flashcards
While caring for a pt w/ a closed head injury, the nurse assesses the pt to be alert w/ a BP 130/90, HR 60, RR 18, and T 102F. To reduce the risk of increased ICP in this pt, What is the priority?
Reduce ambient room temp and administer antipyretics
A nurse is caring for a mechanically ventilated pt with a sustained ICP of 18. The nurse needs to perform an hourly neurological assessment, suction the endotracheal tube, perform oral hygiene care, and reposition the pt to the left side. What is the best action by the nurse?
Provide rest periods between nursing interventions
The nurse is caring for a pt 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage. the nurse assesses the pt to be more lethargic than the previous hour with a blood pressure of 85/50, HR 110, RR 24, O2 95% on 3L/min O2 via nasal cannula, and a T of 101.5. Which provider prescription should the nurse institute first?
500mL albumin infusion intravenously
A nurse is caring for a pt in the ED w/ a suspected cervical spine injury. What is the priority nursing action?
Maintain proper head and neck alignment
A nurse is caring for a pt from a rehabilitation center w/ a preexisting complete cervical spine injury who is complaining of a severe headache. The nurse assesses BP 180/90, HR 60, RR24, and 50mL of urine via indwelling urinary catheter for the past 4hrs. What is the best action by the nurse?
Assess for a kinked urinary catheter and assess for bowl impaction
A nurse is caring for pt w/ bacterial meningitis. To prevent the spread of nosocomial infections to other pts, what is the best action by the nurse?
Implement droplet precautions upon admission
A nurse is caring for a pt who has a diminished level of consciousness on mechanical ventilation. While performing endotracheal suctioning, the pt reaches up in an attempt to grab the suction catheter. What is the best interpretation by the nurse?
The pt is exhibiting purposeful movement
A nurse assesses a pt w/ a skull fracture to have a glasgow coma scale of 3. Additional VS assessed by the nurse include BP 100/70, HR 55, RR 10, O2 94% on oxygen at 3L per nasal cannula. What is the priority nursing action?
Monitor the pts airway patency
A nurse is caring for a pt who was hit on the head w/ a hammer. The pt as unconscious at the scene briefly but is now conscious upon arrival at the ED department w/ a GCS score of 15. One hour later, the nurse assess a GCS score of 3. What is the priority action?
Notify the provider
A nurse is caring for a mechanically ventilated pt admitted w/ a traumatic brain injury. Which ABG value assessed by the nurse indicates optimal gas exchange for a pt w/ this type of injury?
pH 7.38; PaCo2 35, HCO3 24, PaO2 85
A pt w/ a head injury has an ICP of 18. The BP is 144/90 and mean arterial pressure is 108. What is the cerebral perfusion?
90
A nurse is caring for a pt who sustained a closed head injury. After insertion of a ventriculostomy, the nurse assesses the following VS: BP 100/60, HR 52, RR 24, O2 saturation 97% on supplemental oxygen at 45% via venturi mask, GCS score of 4, and ICP of 18. Which order should the nurse institute first?
Mannitol 1g IV
A nurse is caring for a pt w a new onset of slurred speech and right-sided weakness. What is the priority nursing action?
Determine the time of symptom onset
A pt w a complete spinal cord injury has a prescription for solumedrol 30mg/kg over 15min followed in 45min w/ an infusion of 5.4mg/kg/hr for 23hrs. What is the total 24hr dose for the 70kg pt?
10,794
After receiving the handoff report from the day shift charge nurse, which pt should the evening charge nurse assess first?
A pt w/ an ICP of 20 and an oral T of 104
