After the emergency department nurse has received a status report ...

[gonzo233]

After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?
 
  a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture
  b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
  c. A 40-year-old patient who lost conscious-ness for a few seconds after a fall
  d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light

Question 2

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?
 
  a. A 45-year-old receiving IV antibiotics for meningococcal meningitis
  b. A 25-year-old admitted with a skull frac-ture and craniotomy the previous day
  c. A 55-year-old who has increased intracra-nial pressure (ICP) and is receiving hyper-ventilation therapy
  d. A 35-year-old with ICP monitoring after a head injury last week

[Kaytorgator]

Answer to Question 1

ANS: D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased in-tracranial pressure. The other patients are not at immediate risk for complications such as herni-ation.

Answer to Question 2

ANS: A
An RN who works on a medical unit will be familiar with administration of IV antibiotics and with meningitis. The postcraniotomy patient, patient with an ICP monitor, and the patient on a ventilator should be assigned to an RN familiar with the care of critically ill patients.