A 70-year-old patient brought in the ED by family member after falling off the ladder. His medical history includes hypertension, osteoarthritis, and type 2 diabetes mellitus. Upon nursing assessment, he has laceration on his left side of temple and bruises on left patella. His speech is slightly slurred and a weak cough reflex. Patient is alert and oriented X2 and having restlessness. Vital signs: Blood pressure 152/59, pulse 87, respirations 20. Oxygen saturation is 90% room air. He reported having slight headache and tolerable pain of 3/10 on his left knee.

The nurse is reviewing the client' assessment data to prepare the client's plan of care.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experience. 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Increased Intracranial Pressure (ICP)

Based on the patient’s clinical presentation, which includes a fall, slurred speech, weak cough reflex, restlessness, and a slight headache, the patient is at risk for increased intracranial pressure (ICP). The history of falling from a ladder could suggest a possible head injury, and the changes in speech and restlessness could be early signs of increasing ICP. The presence of a laceration on the left temple may also indicate a traumatic brain injury, which is a key risk factor for increased ICP.

Actions to Take:

Apply oxygen via cannula at 2 L/min

Oxygen is critical for brain tissue oxygenation, especially in patients with possible head injuries and ICP. The patient's oxygen saturation is 90% on room air, which is slightly low and requires supplementation to maintain adequate oxygen levels and reduce the risk of hypoxia, which can exacerbate increased ICP.

Elevate the head of the bed to 45 degrees

Elevating the head of the bed to 30-45 degrees can help improve venous drainage from the brain, thus reducing the risk of increased ICP. Positioning the patient in this way also helps reduce pressure on the brain and enhances cerebral perfusion.

Parameters to Monitor:

Level of consciousness (LOC)

Changes in the patient's level of consciousness are a key indicator of worsening ICP. The nurse should assess the patient’s alertness, orientation, and any deterioration in cognitive function or responsiveness. The patient's current orientation level is X2, meaning they are only oriented to person and place, which may signal a developing problem.

Vital signs

Monitoring vital signs, especially blood pressure, heart rate, and respiratory rate, is crucial in assessing the patient's neurological status. Changes in blood pressure (especially widening pulse pressure) or abnormal respiratory patterns can be early indicators of increased ICP. In particular, the patient's blood pressure (152/59) suggests a possible increased risk of ICP, with the systolic value elevated but the diastolic pressure relatively low. This could be a compensatory response to ICP or another issue.

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Correct Answer is D

Explanation

A. Dim vision could be a sign of many conditions but is not the first indicator the nurse should assess for neurologic status.

B. Papilledema (swelling of the optic disc) is a late sign of increased intracranial pressure and is not immediately available on assessment.
C. Body temperature is important but not as directly related to the neurological status as LOC.
D. The level of consciousness (LOC) is one of the most important initial indicators of a patient's neurologic status, as it helps assess brain function and the severity of potential neurological injury. A decrease in LOC can indicate significant brain injury or dysfunction.

A. Restrict head movement. B. Apply cool compresses. C. Keep both eyes patched. D. Eye drops to constrict the pupils will be prescribed.

Correct Answer is A

Explanation

A. After retinal detachment surgery, it is essential to restrict head movement to avoid further damage to the retina or to ensure proper healing post-surgery.
B. Apply cool compresses is not typically recommended before or after retinal detachment surgery, as it could cause discomfort or worsen symptoms.
C. Keep both eyes patched is not necessary unless specifically instructed by the surgeon.
D. Eye drops to constrict the pupils are generally used after surgery but are not a preoperative measure.

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Increased Intracranial Pressure (ICP)

Actions to Take:

Parameters to Monitor:

Nursing Test Bank

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