Nurses in change-of-shift report are discussing the care of a ...

[Kikoku]

Nurses in change-of-shift report are discussing the care of a patient with a stroke who has progressively increasing weakness and decreasing level of consciousness (LOC). Which nursing diagnosis do they determine has the highest priority for the patient?
 
  a. Impaired physical mobility related to weakness
  b. Disturbed sensory perception related to brain injury
  c. Risk for impaired skin integrity related to immobility
  d. Risk for aspiration related to inability to protect airway

Question 2

Which information about the patient who has had a subarachnoid hemorrhage is most important to communicate to the health care provider?
 
  a. The patient complains of having a stiff neck.
  b. The patient's blood pressure (BP) is 90/50 mm Hg.
  c. The patient reports a severe and unrelenting headache.
  d. The cerebrospinal fluid (CSF) report shows red blood cells (RBCs).

[kbennett34]

Answer to Question 1

ANS: D
Protection of the airway is the priority of nursing care for a patient having an acute stroke. The other diagnoses are also appropriate, but interventions to prevent aspiration are the priority at this time.

Answer to Question 2

ANS: B
To prevent cerebral vasospasm and maintain cerebral perfusion, blood pressure needs to be maintained at a level higher than 90 mm Hg systolic after a subarachnoid hemorrhage. A low BP or drop in BP indicates a need to administer fluids and/or vasopressors to increase the BP. An ongoing headache, RBCs in the CSF, and a stiff neck are all typical clinical manifestations of a subarachnoid hemorrhage and do not need to be rapidly communicated to the health care provider.

[Kikoku]

TYSM

[recede]

Excellent