Question 1

The nurse is caring for a patient admitted with new onset of slurred speech,facial droop,and left-sided weakness 8 hours ago.Diagnostic computed tomography scan rules out the presence of an intracranial bleed.Which actions are most important to include in the patient's plan of care? (Select all that apply.)

Accepted Answer

The goal for ischemic stroke is to keep the systolic blood pressure less than 220 mm Hg and the diastolic blood pressure 120 mm Hg.In hemorrhagic stroke,the goal is a mean arterial pressure less than 130 mm Hg.Neurological assessments are compared with the baseline assessments performed in the ED.The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy.The CO₂ should be maintained within normal limits; this value is elevated.The elapsed time of 8 hours since onset of symptoms prohibits thrombolytic therapy.Restraints should be avoided.

Question 2

The nurse is preparing to administer a routine dose of phenytoin (Dilantin).The physician orders phenytoin (Dilantin)500 mg intravenous every 6 hours.What is the best action by the nurse?

Accepted Answer

The ordered dose is an inappropriate maintenance dose.The nurse should contact the physician.Administering the dose over 2 minutes,administering with normal saline,and assessing the cardiac rhythm for bradycardia are normal administration guidelines for normal dose parameters.

Question 3

After receiving the hand-off report from the day shift charge nurse,which patient should the evening charge nurse assess first?

Accepted Answer

The charge nurse should assess the patient with an ICP of 20 mm Hg and a temperature of 104° F as this is an abnormal finding and should be investigated further.A patient with a GCS of 6 being mechanically ventilated has a secure airway and there is no indication of distress.Photophobia is an expected finding with meningitis and droplet precautions are appropriate for a patient with bacterial meningitis.

Question 4

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis.To prevent the spread of nosocomial infections to other patients,what is the best action by the nurse?

Accepted Answer

Droplet precautions are maintained for a patient with bacterial meningitis until 24 hours after the initiation of antibiotic therapy to reduce the potential for spread of the infection.Washing hands and scrubbing the hub of injection ports are practices that help reduce the risk of infection,but added precautions are necessary for preventing the spread of bacterial meningitis.Disposing all bloody dressings in biohazard bags is a standard universal precaution and is not specific to bacterial meningitis.

Question 5

The nurse is preparing to administer 100 mg of phenytoin (Dilantin)to a patient in status epilepticus.To prevent patient complications,what is the best action by the nurse?

Accepted Answer

Ensuring a patent IV site prevents complications associated with infiltration of the medication (soft tissue necrosis).Mixing the drug with normal saline prevents crystallization of the medication and would be noticed prior to administration.Evaluating the serum K⁺ is not required prior to administration.The dose of phenytoin (Dilantin)ordered can be safely administered IV push over 2 minutes and does not require an infusion pump.

Question 6

The nurse is preparing to monitor intracranial pressure (ICP)with a fluid-filled monitoring system.The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.)

Accepted Answer

Neither heparin nor pressure bags nor pressurized flush systems are used for ICP monitoring setups.ICP is recorded as a mean value with the transducer system zero referenced at the level of the foramen of Munro.Manually flushing the device may result in an increase in ICP.

Question 7

The nurse is caring for a patient admitted to the emergency department in status epilepticus.Vital signs assessed by the nurse include blood pressure 160/100 mm Hg,heart rate 145 beats/min,respiratory rate 36 breaths/min,oxygen saturation (SpO₂)96% on 100% supplemental oxygen by non-rebreather mask.After establishing an intravenous (IV)line,which order by the physician should the nurse implement first?

Accepted Answer

The nurse should administer lorazepam (Ativan)as ordered; lorazepam (Ativan)is the first-line medication for the treatment of status epilepticus.Phenytoin (Dilantin)is administered only when lorazepam fails to stop seizure activity or if intermittent seizures persist for longer than 20 minutes.Serum electrolytes and chest x-rays are appropriate orders but not the priority in this scenario.

Question 8

The nurse is caring for a patient admitted with bacterial meningitis.Vital signs assessed by the nurse include blood pressure 110/70 mm Hg,heart rate 110 beats/min,respiratory rate 30 breaths/min,oxygen saturation (SpO₂)95% on supplemental oxygen at 3 L/min,and a temperature 103.5° F.What is the priority nursing action?

Accepted Answer

Bacterial meningitis is an infection of the pia and arachnoid layers of the meninges and the cerebrospinal fluid (CSF)in the subarachnoid space.As such,the patient can experience symptoms associated with cerebral irritation such photophobia and seizures.In addition,the patient is at increased risk for seizures because of a high temperature.The priority nursing action is to implement seizure precautions in an attempt to prevent injury.Elevating the head of the bead,keeping the lights dim,and maintaining bedrest are all appropriate nursing interventions but are not the priorities in this scenario.

Question 9

In an unconscious patient,eye movements are tested by the oculocephalic response.Which statements regarding the testing of this reflex are true? (Select all that apply.)

Accepted Answer

In unconscious patients with stable cervical spine,assess oculocephalic reflex (doll's eye): turn the patient's head quickly from side to side while holding the eyes open.Note movement of eyes.The doll's eye reflex is present if the eyes move bilaterally in the opposite direction of the head movement.

Question 10

The nurse is to administer 100 mg phenytoin (Dilantin)intravenous (IV).Vital signs assessed by the nurse include blood pressure 90/60 mm Hg,heart rate 52 beats/min,respiratory rate 18 breaths/min,and oxygen saturation (SpO₂)99% on supplemental oxygen at 3 L/min by cannula.To prevent complications,what is the best action by the nurse?

Accepted Answer

In the presence of hypotension and bradycardia,administering the medication over 2 minutes is too fast.Mixing medication with 0.9% normal saline prevents precipitation of the medication but will not prevent complications related to this scenario.Administering the medications via central line will not prevent complications related to this scenario.

Question 11

The nurse,caring for a patient following a subarachnoid hemorrhage,begins a nicardipine (Cardene)infusion.Baseline blood pressure assessed by the nurse is 170/100 mm Hg.Five minutes after beginning the infusion at 5 mg/hr,the nurse assesses the patient's blood pressure to be 160/90 mm Hg.What is the best action by the nurse?

Accepted Answer

Medications to control blood pressure are administered to prevent rebleeding before an aneurysm is secured.Following infusion,the patient's blood pressure remains dangerously high,so increasing the dose by 2.5 mg/hr is the best action by the nurse.Stopping the infusion or weaning the infusion is contraindicated before reaching the desired blood pressure.Notifying the physician of the blood pressure is not indicated until the upper limits of the infusion are reached without achieving the desired blood pressure.

Question 12

The physician orders fosphenytoin (Cerebyx),1.5 g intravenous (IV)loading dose for a 75-kg patient in status epilepticus.What is the most important action by the nurse?

Accepted Answer

The nurse can administer the medication over 10 minutes as ordered (100-150 mg phenytoin equivalent [PE] over 1 full minute).The drug dose ordered is appropriate for the patient's weight.Fosphenytoin (Cerebyx)does not have to be administered with normal saline or via a central line.

Question 13

The nurse is caring for a patient 5 days following clipping of an anterior communicating artery aneurysm for a subarachnoid hemorrhage.The nurse assesses the patient to be more lethargic than the previous hour with a blood pressure 95/50 mm Hg,heart rate 110 beats/min,respiratory rate 20 breaths/min,oxygen saturation (SpO₂)95% on 3 L/min oxygen via nasal cannula,and a temperature of 101.5° F.Which physician order should the nurse institute first?

Accepted Answer

Cerebral vasospasm is a life-threatening complication following subarachnoid hemorrhage.Once an aneurysm has been repaired surgically,blood pressure is allowed to rise to prevent vasospasm.Volume expansion with 500 mL albumin is the priority intervention for a blood pressure of 95/50 mm Hg to prevent vasospasm and ensure cerebral perfusion.Blood cultures,acetaminophen administration,and Decadron are appropriate to include in the plan of care but are not priorities in this scenario.

Question 14

The nurse receives a patient from the emergency department following a closed head injury.After insertion of an ventriculostomy,the nurse assesses the following vital signs: blood pressure 100/60 mm Hg,heart rate 52 beats/min,respiratory rate 24 breaths/min,oxygen saturation (SpO₂)97% on supplemental oxygen at 45% via Venturi mask,Glasgow Coma Scale score of 4,and intracranial pressure (ICP)of 18 mm Hg.Which physician order should the nurse institute first?

Accepted Answer

The patient's GCS score is 4 along with an ICP of 18 mm Hg.Although a portable chest x-ray and seizure precautions are appropriate to include in the plan of care,Mannitol 1 g intravenous is the priority intervention to reduce intracranial pressure.Ancef 1 g intravenous is appropriate given the indwelling ICP line; however,antibiotic therapy is not the priority in this scenario.

Question 15

The nurse is caring for a patient admitted with a subarachnoid hemorrhage following surgical repair of the aneurysm.Assessment by the nurse notes blood pressure 90/60 mm Hg,heart rate 115 beats/min,respiratory rate 28 breaths/min,oxygen saturation (SpO₂)99% on supplemental oxygen at 3L/min by cannula,a Glasgow Coma Score of 4,and a central venous pressure (CVP)of 2 mm Hg.After reviewing the physician orders,which order is of the highest priority?

Accepted Answer

To ensure adequate cerebral perfusion,for a CVP of 2 mm Hg,blood pressure of 90/60 mm Hg,and heart rate of 115 beats/min,an infusion of 500 mL of albumin is most appropriate.Lasix is contraindicated in low volume states.Although Decadron and Dilantin are appropriate medications,in this scenario,they are not the priority medications.

Quiz 13: Nervous System Alterations

The nurse is preparing to administer a routine dose of phenytoin (Dilantin) .The physician orders phenytoin (Dilantin) 500 mg intravenous every 6 hours.What is the best action by the nurse?

After receiving the hand-off report from the day shift charge nurse,which patient should the evening charge nurse assess first?

The nurse has just received a patient from the emergency department with an admitting diagnosis of bacterial meningitis.To prevent the spread of nosocomial infections to other patients,what is the best action by the nurse?

The nurse is preparing to administer 100 mg of phenytoin (Dilantin) to a patient in status epilepticus.To prevent patient complications,what is the best action by the nurse?

The nurse is preparing to monitor intracranial pressure (ICP) with a fluid-filled monitoring system.The nurse understands which principles and/or components to be essential when implementing ICP monitoring? (Select all that apply.)

In an unconscious patient,eye movements are tested by the oculocephalic response.Which statements regarding the testing of this reflex are true? (Select all that apply.)

The physician orders fosphenytoin (Cerebyx) ,1.5 g intravenous (IV) loading dose for a 75-kg patient in status epilepticus.What is the most important action by the nurse?