Which parameter would the nurse use to assess whether the patient is oriented Quizlet
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Terms in this set (29)which questions does the nurse ask when conducting an expanded assessment to determine patient orientation? select all that apply A. what is your name? B, C, D, E the nurse is caring for a pt with a basiliar skull fracture and an intracranial pressure of 17mmHg, mean arterial pressure of 85 mmHg and a cerebral perfusion pressure of 68 mmHg. what is the priority intervention for this patient? A. elevate the head of the bed to 30 degrees A. elevate the head of the bed to 30 degrees the nurse is reviewing orders written for a pt returning from surgery to remove a spinal cord tumor. which order should the nurse implement immediately? A. install a bed cradle C. Dexamethasone (Decadaron) 10 mg IVP now and every 8 hours x 2 doses the nurse notes that a pt with low back pain is experiencing radiculopathy. what should the nurse expect when assessing this pt? select all that apply A. pain A, C, D, E the nurse provides care for a pt who is prescribed a serum osmolality for the management of increased intracranial pressure (ICP). which is an appropriate action by the nurse? A. ensure the pt remains completely still during the test D. draw the blood within one to two hours of osmotic diuretic administration when caring for a pt who has had a head injury, which assessment information requires the immediate action by the nurse? A. a pt who is more difficult to arouse than she was 1 hour ago A. a pt who is more difficult to arouse than she was 1 hour ago the nurse is caring for a pt with a large epidural hematoma who is intubated and on the ventilator. the physician instructs the nurse to hyperventilation the pt. the nurse understands the best rationale for this action is which of the following? A. increase the pts PaCO2 to lower intracranial pressure B. decrease the pts PaCO2 to lower intracranial pressure After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first? d. A patient whose right pupil is 10 mm and unresponsive to light a patient with multiple sclerosis is admitted for treatment of clinical manifestations. what should the nurse expect to be prescribed for this patient? A. corticosteroids C. muscle relaxants your patient arrives after an MVA with a GCS of 8. the MD decides to intubate. what is the rational for intubation? A. the level of consciousness is altered, and the patient may not be able to maintain a patent airway A. the level of consciousness is altered, and the patient may not be able to maintain a patent airway you are caring for a pt with a recent spinal cord injury. the pt develops a sudden, pounding headache and hypertension. what is your best first action? A. administer metoprolol 5 mg IVP B. elevate the head of the bed at least 45 degrees or place the pt in a sitting position an unconscious pt has a nursing diagnosis of ineffective cerebral tissue perfusion r/t cerebral tissue swelling. which nursing interventions will be included in the plan of care? A. elevated the head of the bed to 30 degrees A. elevated the head of the bed to 30 degrees why is a 3% sodium chloride ordered for a pt with increased ICP? A. it is a hypotonic solution and will be used to decrease brain tissue swelling C. it is a hypertonic solution that will be used to decrease brain swelling an 18 year old female is admitted to the ICU with a skull fracture after a motor vehicle accident. her nurse notices that the pt has what appears to be blood leaking from her nose and decides to test the fluid. what finding would indicate to the nurse that th pt has leakage of CSF? A. battle's sign C. halo sign the nurse is assessing a patient's level of consciousness after a brain injury using the Glasgow Coma Scale. the patient's eyes open to painful stimuli only, but he does not respond verbally to the painful stimuli. he is also decorticate posturing. approximately what should the nurse rate his GCS score? A. 2-3 B. 5-6 a nursing student is helping care for a pt on the ventilator with positive brain swelling, which causes him to have an increased ICP. which action by the student would require intervention by the nurse? A. the student positions the head of the patient's bed at 30 degrees B. the student suctions the pt for 10 seconds, three times in a row to ensure all secretion have been cleared from the patient's airway Which parameter is best for the nurse to monitor to determine whether the prescribed IV mannitol (Osmitrol) has been effective for an unconscious
patient? d. Intracranial pressure the latest blood pressure reading for a pt with a spinal cord injury is 210/140 mmHg. what action should the nurse take first? A. palpate for bladder distension D. raise the head of the bed 45 degrees the patient is experiencing increasing flaccid upper arm while the lower extremities periodically cramp and contract. on which health problem should the nurse focus when assessing this patient? A. brain tumor D. amyotrophic lateral sclerosis (ALS) the nurse provides care for a patient who is 4 hr post-op to correct a herniated nucleus pulposus. which assessment finding causes the nurse to notify the health-care provider? A. the pt is drowsy but arousable B. the pts respiratory rate is 9 bpm the nurse provides care to a pt who is diagnosed with increased intracranial pressure (ICP). which finding indicates the need for intermediate intervention? A. lethargy C. contralateral hemiparesis pt is a 22 y/o female who has been on a 3 day party binge. her friends bring her to the ED after being unable to awaken her. assessment reveals shallow respirations with rate of 8/min,
diminished breath sounds, and decreased LOC. respiratory acidosis due to hypoventilation pt is a 22 y/o female who has been on a 3 day party binge. her friends bring her to the ED after being unable to awaken her. assessment reveals shallow respirations with rate of 8/min, diminished breath sounds, and decreased
LOC. renal system would increase bicarb level (make up for what respiratory could not do) pt is a 22 y/o female who has been on a 3 day party binge. her friends bring her to the ED after being unable to awaken her. assessment reveals shallow respirations with rate of 8/min, diminished breath sounds, and decreased LOC. mechanical ventilation 6 days after kidney transplantation from a deceased donor, a patient develops a temperature of 101.2 F (38.5C), tenderness at the transplant sit, and oliguria. the nurse recognizes that these findings indicate... A. acute rejection, which is not uncommon and is usually reversible A. acute rejection, which is not uncommon and is usually reversible the nurse is administering 3.0% solution IV to a pt with severe hyponatremia. it is most important for the nurse to observe for what? A. decreased HR and BP C. SOB and increased RR a pt is admitted with renal failure and an arterial blood pH of 7.29. which lab result would the nurse expect? A. serum sodium 138 mEq/L D. serum potassium 5.9 mEq/L a patient with an acid-base imbalance has an altered potassium level. the nurse recognizes that the potassium level is altered because... A. potassium is returned to extracellular fluid when metabolic acidosis is corrected C. acidosis causes hydrogen ions in the blood to be exchanged for potassium from the cells a pt has the following ABG results: pH 7.48, PaO2 86 mmHg, PaCO2 44 mmHg, HCO3 28 mEq/L. when assessing the pt, the nurse would expect the pt to have? A. muscle cramping A. muscle cramping Sets found in the same folderCritical Care Exam 3 Quiz Questions29 terms madisonperryyy Critical Care Exam 1153 terms sidneyrichh CC2 PQ45 terms hannah_mosley3 Chapter 9: Acid-Base Balance30 terms alvin_lai1 Other sets by this creatorcritical care test 1127 terms kelssteed Critical Care 1 kahoot questions32 terms kelssteed peds exam 4 practice questions12 terms kelssteed peds practice questions30 terms kelssteed Other Quizlet setsYerma Session 2 - Análisis de los personajes34 terms quizlette8477842 Micro lab test 1110 terms arelys10 Project Management Exam 239 terms Pbrasili CH 47 F Limits25 terms caleb_miller63PLUS Related questionsQUESTION When reading a play Spectacle is the most important of Aristotle's 6 parts? 15 answers QUESTION Who calls Cathy and ask her out? 2 answers QUESTION Which of these data types are used to store true or false values 6 answers QUESTION What is the genitive singular of "mater bona"? 7 answers |
