The nurse admits a patient to the critical care unit following a motorcycle crash.Assessment findings by the nurse include blood pressure 100/50 mm Hg,heart rate 58 beats/min,respiratory rate 30 breaths/min,and temperature of 100.5°F.The patient is lethargic,responds to voice but falls asleep readily when not stimulated.Which nursing action is most important to include in this patient's plan of care?

Question

Quizplus · Accepted Answer

Nurses complete neurological assessments based on prescribed frequency and the severity of the patient's condition.The newly admitted patient has an altered neurological status,so frequent neurological assessments are most important to include in the patient's plan of care.Side to side position changes,range-of-motion exercises,and frequent oral suctioning are nursing actions that may need to be a part of the patient's plan of care,but in the setting of increased intracranial pressure they should not be regularly performed unless indicated.

The Nurse Admits a Patient to the Critical Care Unit