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Author Question: The nurse completes an assessment of a patient on the neurology unit. After reviewing the results ... (Read 33 times)

jwb375

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The nurse completes an assessment of a patient on the neurology unit. After reviewing the results listed in the table, what coma state does the nurse realize this patient is experiencing?
 
  1. persistent vegetative
  2. stupor
  3. locked-in syndrome
  4. minimally conscious

Question 2

The nurse is caring for a patient with an intracranial pressure monitoring device. For which priority problem should the nurse plan care for this patient?
 
  1. possible infection
  2. confusion
  3. changes in skin integrity
  4. changes in mobility status



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fauacakatahaias

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Answer to Question 1

Correct Answer: 1
Persistent vegetative state (irreversible coma) is a permanent condition characterized by complete unawareness of self and the environment and loss of all cognitive functions. The patient has sleepwake cycles and can chew, swallow, and cough. When awake, the eyes wander but cannot track objects or persons. The patient may grasp objects and respond to physical stimuli but not upon command. In stupor the patient is generally unresponsive but may arouse to vigorous or painful stimuli. The patient in locked-in syndrome is alert and fully aware of the environment and has intact cognitive abilities but is unable to communicate through speech or movement. The minimally conscious patient is aware of the environment and can follow simple commands, manipulate objects, gesture or verbalize yes/no responses, and make meaningful movements in response to stimuli.

Answer to Question 2

Correct Answer: 1
Intracranial monitoring is more invasive than other monitoring devices and disrupts skin and skeletal barriers. It is often used on patients with impaired immune defenses. It necessitates frequent flushing and monitoring and may be an open system, which offers increased opportunity for pathogens to enter and grow. Confusion, skin integrity, and mobility status are not considered priority problems for the patient with an intracranial pressure monitoring device.





 

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