A nurse is caring for four clients in the ...

[rlane42]

A nurse is caring for four clients in the neurologic/neurosurgical intensive care unit. Which client should the nurse assess first?
 
  a. Client who has been diagnosed with meningitis with a fever of 101  F (38.3  C)
  b. Client who had a transient ischemic attack and is waiting for teaching on clopidogrel (Plavix)
  c. Client receiving tissue plasminogen activator (t-PA) who has a change in respiratory pattern and rate
  d. Client who is waiting for subarachnoid bolt insertion with the consent form already signed

Question 2

The nurse assesses a client's Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client?
 
  a. Can ambulate independently
  b. May have trouble swallowing
  c. Needs frequent re-orientation
  d. Will need near-total care

[bulacsom]

Answer to Question 1

ANS: C
The client receiving t-PA has a change in neurologic status while receiving this fibrinolytic therapy. The nurse assesses this client first as he or she may have an intracerebral bleed. The client with meningitis has expected manifestations. The client waiting for discharge teaching is a lower priority. The client waiting for surgery can be assessed quickly after the nurse sees the client who is receiving t-PA, or the nurse could delegate checking on this client to another nurse.

Answer to Question 2

ANS: C
This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.