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AndyWang AndyWang
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Posts: 366
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6 years ago
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 2

After 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 3

When 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 4

A 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 5

The 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.
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Replies
wrote...
6 years ago
The answer to question 1

ANS: A
The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

The answer to question 2

ANS: B
Because suctioning will cause a transient increase in intracranial pressure, the nurse should ini-tially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to noti-fy the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure.

The answer to question 3

ANS: D
Shock is a serious complication of meningitis, and the patient's low blood pressure indicates the need for interventions such as fluids or vasopressors. Nuchal rigidity and a positive Kernig's sign are expected with bacterial meningitis. The nurse should intervene to lower the temperature, but this is not as life threatening as the hypotension.

The answer to question 4

ANS: B
Calculate the cerebral perfusion pressure (CPP): (CPP = mean arterial pressure MAP  ICP). MAP = DBP + 1/3 (systolic blood pressure SBP  diastolic blood pressure DBP). Therefore the (MAP) is 70 and the CPP is 56 mm Hg, which is below the normal of 60 to 100 mm Hg and approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the cerebral perfusion pressure. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

The answer to question 5

ANS: C
The Neisseria meningitides vaccination is recommended for children ages 11 and 12, unvac-cinated teens entering high school, and college freshmen. Hand washing may help decrease the spread of bacteria, but it is not as effective as immunization. Vaccination with Haemophilus in-fluenzae is for infants and toddlers. Because adolescents and young adults are in school or the workplace, avoiding crowds is not realistic.
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