A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?
a. Administer IV 5 hypertonic saline.
b. Draw blood for arterial blood gases (ABGs).
c. Send patient for computed tomography (CT).
d. Administer acetaminophen (Tylenol) 650 mg orally.
Question 2After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?
a. Document the increase in intracranial pressure.
b. Ensure that the patient's neck is in neutral position.
c. Notify the health care provider about the change in pressure.
d. Increase the rate of the prescribed propofol (Diprivan) infusion.
Question 3When assessing a 53-year-old patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider?
a. The patient exhibits nuchal rigidity.
b. The patient has a positive Kernig's sign.
c. The patient's temperature is 101 F (38.3 C).
d. The patient's blood pressure is 88/42 mm Hg.
Question 4A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first?
a. Document the BP and ICP in the patient's record.
b. Report the BP and ICP to the health care provider.
c. Elevate the head of the patient's bed to 60 degrees.
d. Continue to monitor the patient's vital signs and ICP.
Question 5The public health nurse is planning a program to decrease the incidence of meningitis in adoles-cents and young adults. Which action is most important?
a. Encourage adolescents and young adults to avoid crowds in the winter.
b. Vaccinate 11- and 12-year-old children against Haemophilus influenzae.
c. Immunize adolescents and college fresh-man against Neisseria meningitides.
d. Emphasize the importance of hand wash-ing to prevent the spread of infection.