A client has a traumatic brain injury. The nurse assesses the ...

[LCritchfi]

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority?
 
  a. Call the provider or Rapid Response Team.
  b. Increase the rate of the IV fluid administration.
  c. Notify respiratory therapy for a breathing treatment.
  d. Prepare to give IV pain medication.

Question 2

A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the docusate sodium (Colace) because the client had a large stool earlier. What action by the supervising nurse is best?
 
  a. Have the student ask the client if it is desired or not.
  b. Inform the student that the docusate should be given.
  c. Tell the student to document the rationale.
  d. Tell the student to give it unless the client refuses.

[TheNamesImani]

Answer to Question 1

ANS: A
These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication.

Answer to Question 2

ANS: B
Stool softeners should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Valsalva maneuver when constipated. The supervising nurse should instruct the student to administer the docusate. The other options are not appropriate. The medication could be held for diarrhea.

[LCritchfi]

TYSM

[recede]

Excellent