The nurse is caring for a patient who has a head injury and fractured right arm after being as-saulted. Which assessment information requires the most rapid action by the nurse?
a. The apical pulse is slightly irregular.
b. The patient complains of a headache.
c. The patient is more difficult to arouse.
d. The blood pressure (BP) increases to 140/62 mm Hg.
Question 2A patient has increased intracranial pressure and a ventriculostomy after a head injury. Which action can the nurse delegate to unlicensed assistive personnel (UAP) who regularly work in the intensive care unit?
a. Document intracranial pressure every hour.
b. Turn and reposition the patient every 2 hours.
c. Check capillary blood glucose level every 6 hours.
d. Monitor cerebrospinal fluid color and volume hourly.
Question 3A 68-year-old male patient is brought to the emergency department (ED) by ambulance after be-ing found unconscious on the bathroom floor by his spouse. Which action will the nurse take first?
a. Check oxygen saturation.
b. Assess pupil reaction to light.
c. Verify Glasgow Coma Scale (GCS) score.
d. Palpate the head for hematoma or bony irregularities.
Question 4The charge nurse observes an inexperienced staff nurse caring for a patient who has had a crani-otomy for resection of a brain tumor. Which action by the inexperienced nurse requires the charge nurse to intervene?
a. The staff nurse assesses neurologic status every hour.
b. The staff nurse elevates the head of the bed to 30 degrees.
c. The staff nurse suctions the patient rou-tinely every 2 hours.
d. The staff nurse administers an analgesic before turning the patient.
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