Answer to Question 1
Correct Answer: 1
Persistent vegetative state (irreversible coma) is a permanent condition characterized by complete unawareness of self and the environment and loss of all cognitive functions. The patient has sleepwake cycles and can chew, swallow, and cough. When awake, the eyes wander but cannot track objects or persons. The patient may grasp objects and respond to physical stimuli but not upon command. In stupor the patient is generally unresponsive but may arouse to vigorous or painful stimuli. The patient in locked-in syndrome is alert and fully aware of the environment and has intact cognitive abilities but is unable to communicate through speech or movement. The minimally conscious patient is aware of the environment and can follow simple commands, manipulate objects, gesture or verbalize yes/no responses, and make meaningful movements in response to stimuli.
Answer to Question 2
Correct Answer: 1
Intracranial monitoring is more invasive than other monitoring devices and disrupts skin and skeletal barriers. It is often used on patients with impaired immune defenses. It necessitates frequent flushing and monitoring and may be an open system, which offers increased opportunity for pathogens to enter and grow. Confusion, skin integrity, and mobility status are not considered priority problems for the patient with an intracranial pressure monitoring device.
Critical thinking involves analysis in which the nurse examines patient data available from a variet
Position of patient to assess jugular vein distention
Example of a patient statement.
Patient health history form Cont.
ROM exercises on a patient’s wrist: radial deviation.
Results of disrupted control of skeletal muscles