A male patient who has possible cerebral edema has a serum sodium ...

[crazycityslicker]

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now complaining of a headache. Which prescribed interventions should the nurse implement first?
 
  a. Administer IV 5 hypertonic saline.
  b. Draw blood for arterial blood gases (ABGs).
  c. Send patient for computed tomography (CT).
  d. Administer acetaminophen (Tylenol) 650 mg orally.

Question 2

After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first?
 
  a. Document the increase in intracranial pressure.
  b. Ensure that the patient's neck is in neutral position.
  c. Notify the health care provider about the change in pressure.
  d. Increase the rate of the prescribed propofol (Diprivan) infusion.

[josephsuarez]

Answer to Question 1

ANS: A
The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

Answer to Question 2

ANS: B
Because suctioning will cause a transient increase in intracranial pressure, the nurse should ini-tially check for other factors that might be contributing to the increase and observe the patient for a few minutes. Documentation is needed, but this is not the first action. There is no need to noti-fy the health care provider about this expected reaction to suctioning. Propofol is used to control patient anxiety or agitation. There is no indication that anxiety has contributed to the increase in intracranial pressure.

[crazycityslicker]

Excellent

[emsimon14]

TYSM