The nurse is caring for four clients with traumatic brain ...

[storky111]

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
 
  a. Client with cerebral perfusion pressure of 72 mm Hg
  b. Client who has a Glasgow Coma Scale score of 12
  c. Client with a PaCO2 of 36 mm Hg who is on a ventilator
  d. Client who has a temperature of 102  F (38.9  C)

Question 2

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death?
 
  a. Client with a core temperature of 95  F (35  C) for 2 days
  b. Client in a coma for 2 weeks from a motor vehicle crash
  c. Client who is found unresponsive in a remote area of a field by a hunter
  d. Client with a systolic blood pressure of 92 mm Hg since admission

[xMRAZ]

Answer to Question 1

ANS: D
A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.

Answer to Question 2

ANS: B
In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.